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Objectives: Organ preserving surgery (OPS) and radiotherapy (RT) are both accepted treatment options for early stage supraglottic cancer (SGC). Radiation has supplanted surgery in most cases, because of the perception that surgery results in poorer functional outcomes. However, evidence suggests that OPS with a neck dissection may be associated with improved survival. Our objective was to conduct a systematic review of the literature to compare functional outcomes of OPS and RT for early SGC., Methods: We searched Medline, EMBASE and Cochrane Central Register of Controlled Trials to identify studies. Studies were included if they reported functional outcomes on 10 or more patients with early stage SGC treated with radiation or OPS, including open partial laryngectomy, transoral laser microsurgery (TLM) or transoral robotic surgery (TORS). Two reviewers independently screened articles for relevance using pre-determined criteria., Results: From 7720 references, we included 10 articles (n = 640 patients). 50% (n = 320) of patients were treated with surgery. Three head-to-head RT versus OPS papers were included, however different outcome measures were used for each group. Intractable aspiration management (including total laryngectomy or permanent tracheostomy) following OPS was reported in five papers representing 186 patients; the definitive intractable aspiration management rate was 2.6% (95% CI 1.0-6.8%). Four papers reported permanent G-tube rate for the surgical group (n = 198), calculating a rate of 5.3% (95% CI 2.6-10.5%), this was not reported for the RT group in any papers. One study reported quality of life. Two studies reported objective voice measures., Conclusions: This systematic review revealed a paucity of objective measures and significant data heterogeneity, rendering the comparison of functional outcomes following OPS versus RT for early SGC limited. Future research should include objective measures of functional outcomes including laryngectomy rate, g-tube rate, tracheostomy dependence, quality of life, and voice quality measures.

Objectives: For early stage supraglottic squamous cell carcinoma (SCC), single modality treatment either in the form of primary organ preservation surgery alone or radiation alone is recommended. Thus, a definite treatment strategy for early stage supraglottic SCC remains undefined. The primary objective of this study was to conduct a systematic review and meta-analysis comparing the oncologic outcomes of surgery and radiotherapy in early stage (Stage I and II) T1 N0 and T2 N0 supraglottic SCC., Methods: Systematic methods were used to identify published and unpublished data. Two reviewers independently screened all titles, abstracts and articles for relevance using predefined criteria. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated., Results: Five studies met the inclusion criteria for disease specific mortality with a total of 2864 pooled patients. 5-year disease specific mortality was lower in the surgery group (ORs 0.43, 95% CI 0.31-0.60). Four studies met the inclusion criteria for 5-year overall mortality with a total of 2790 pooled patients. Five-year overall mortality was lower in surgery group (ORs 0.40, 95% CI 0.29-0.55)., Conclusions: This is the first study to examine the management of early stage supraglottic SCC using meta-analytic methodology. Our results suggest that primary surgery may result in decreased disease specific and overall mortality compared to primary radiotherapy.

Both early and advanced stage laryngeal cancers are treated with organ-preserving strategies including radiation alone or concurrent chemoradiotherapy. While organ-preserving modalities have proven effective in eradicating cancer while also preserving laryngeal function, there remains a proportion of cases where residual or recurrent cancer prevails, or conversely, where radiotherapy renders a larynx dysfunctional. In these circumstances, salvage total laryngectomy is often the surgical treatment. The effects of radiotherapy to the neck, amplified by chemotherapy, can create an inhospitable surgical environment, making the salvage laryngectomy an operation fraught with the potential for major complications such as the dreaded pharyngocutaneous fistula. The introduction of vascularized tissue from outside the irradiated field decreases the risk of major wound complications. Free tissue transfer, with a variety of donor sites available, is commonly employed to reconstruct either a patch or a circumferential segment of the pharynx. When there is enough pharyngeal mucosa for primary closure, a vascularized onlay graft or a pharyngeal interposition graft can be used to reinforce the closure. This has been demonstrated to both reduce the severity of pharyngocutaneous fistula and decrease the risk of developing a pharyngocutaneous fistula compared to primary closure alone. Beyond mitigating the risk for perioperative complications, flap selection may have implications on the long-term outcomes after salvage total laryngectomy and these must be considered preoperatively. The purpose of this review is to examine the various options for reconstruction after salvage total laryngectomy and to examine some of their advantages and disadvantages in the short and long-term., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives/hypothesis: Common endpoints in reporting the outcomes for early glottic cancer do not highlight the importance of organ preservation. We evaluated the treatment outcomes among patients with T1aN0 laryngeal cancer with laryngectomy-free disease-specific survival (LFS-DSS), which is defined as time to total laryngectomy or time to death from cancer cause, against all other endpoints., Study Design: Outcome research on an institutional database., Methods: A retrospective review covered all consecutive patients from 2003 to 2013. Patients with T1a laryngeal squamous cell carcinoma (SCC) were offered the options of either radiation treatment (RT) or transoral laser microsurgery (TLM). Tumor control, survival outcomes, standard definition laryngectomy-free survival (LFS), and LFS-DSS were calculated., Results: There were 105 patients, of whom 53 were treated with TLM and 52 were treated with RT. There were 11 recurrences within the TLM group, of which four were successfully salvaged with repeated TLM and two were salvaged with RT. Among the four recurrences within the RT group, all four patients had salvage total laryngectomies. The 5-year overall survival for patients treated with TLM versus RT was 86% versus 85% (P = .887), disease-free survival was 69% versus 78% (P = .151), LFS was 65% versus 77% (P = .198), LFS-DSS was 100% versus 88% (P = .030), and ultimate locoregional control was 100% in both groups., Conclusions: Patients with T1aN0 glottic SCC treated with RT or TLM have similar survival outcomes. Patients with T1a tumor treated with TLM have better organ preservation compared to RT, when measured with LFS-DSS., Level of Evidence: 4. Laryngoscope, 127:1322-1327, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Because of the significant toxicity of chemoradiation regimens, there has been a resurgence of interest in the primary surgical management of head and neck cancer and, in particular, the use of minimally invasive surgery. One such technique is transoral robotic surgery (TORS). We aim to discuss the potential role of TORS in patients requiring total laryngectomy (TL)., Methods and Results: Three patients underwent TORS-assisted narrow-field TL. Relative data on preoperative, intraoperative, and postoperative management were collated including postoperative complications., Conclusions: We present 3 cases of transoral robotic surgery (TORS)-assisted TL in patients requiring narrow field laryngectomy without requirement for neck dissection. In reviewing these cases we provide a discussion of pertinent preoperative and intraoperative considerations that can assist in facilitating successful completion of the procedure. In particular, appropriate assessment at the pinsertlinePOLA_Del_Blank_PgPOLA_Shift_FramePORT_rem_fpg_underremovelinetabminilanning endoscopy in addition to a methodical surgical approach are vital to the successful use of the robot in TORS-assisted TL., (Copyright © 2012 Wiley Periodicals, Inc.)

Objective: To assess the oncological and functional outcomes of T1b squamous cell carcinoma (SCC) of the glottic larynx treated with laser in comparison with radiation., Design: A Canadian multicenter cohort study., Setting: Three tertiary referral centers for head and neck cancer- Dalhousie University in Halifax, Nova Scotia, Western University in London, Ontario and the University of Manitoba, Winnipeg., Methods: Patients with T1b glottic SCC who underwent transoral laser resection or radiation as the primary modality of treatment., Outcome Measures: Oncological outcomes were evaluated using local control, laryngeal preservation, disease free survival and disease specific survival. Voice outcomes were assessed using the Voice Handicap Index-10 (VHI-10)., Results: 63 patients met study criteria. 21 were treated with laser and 42 with radiation. Oncologic outcomes at 2 years for laser and radiation demonstrated local control of 95% and 85.9%; laryngeal preservation of 100% and 85.9%; disease free survival of 88.7% and 85.9% and overall survival of 94.1% and 94.8% respectively. VHI-10 data was available for 23/63 patients. During the last follow up visit VHI-10 ranged from 0 to 11 (median 6) in the laser group and 0 to 34 (median 7) in the radiation group., Conclusion: T1b SCC of the glottis can be effectively treated with transoral laser microsurgery with oncological outcomes that are at least equivalent to radiation. For patients with VHI scores, voice quality was similar between the two groups. To our knowledge this is the first study directly comparing the oncologic and voice outcomes with laser and radiation for the treatment of glottic cancer involving the anterior commissure.

Objective: To compare the laryngeal preservation rates and voice outcomes after treatment of early glottic cancer between transoral laser microsurgery (TLM) and radiotherapy (RT)., Design: Multicenter, retrospective consecutive cohort of stage 1 and 2 glottic carcinoma treated with TLM or RT., Setting: Three Canadian academic cancer centres., Methods and Main Outcome Measures: The patients were those of the regional cancer registries associated with each of the participating universities between 2002 and 2010. The primary oncologic end point was organ preservation. The primary functional outcome measure was the Voice Handicap Index (VHI-10)., Results: A total of 234 patients were treated for early glottic cancer (143 TLM, 91 RT). At 2 years, the laryngeal preservation rate for stage 1 disease was 100% TLM and 92% RT (p < .004); for stage 2 disease, it was 100% TLM and 88% RT (p  =  not significant). There was only one laryngectomy in the TLM group over 5 years posttreatment. There were functional data on 132 patients (83 TLM, 49 RT). Median VHI-10 scores were inferior for laser patients at all three time intervals (6, 12, and 24-48 months posttreament) despite a stage bias in favour of TLM (range of median VHI score over time intervals: TLM  =  9.5-12, RT  =  3.5-8; p  =  .01-.08). However, theses scores represent mild disability in both groups., Conclusions: TLM patients have poorer voice quality than RT patients. However, the advantages of TLM in most patients outweigh the degree of voice handicap. Organ preservation rates for TLM were better than or equal to those of RT for both stage 1 and 2 glottic cancer.

Background: Early-stage laryngeal squamous cell carcinoma is managed with radiotherapy or endoscopic surgery. Although cure rates are high, radiation failures often require total laryngectomy for salvage. Biomarkers that can predict tumour radioresistance may be useful in modifying the treatment approach for individual patients., Methods: Retrospective patient chart review yielded 75 patients with T1-T2 glottic squamous cell carcinoma treated with radiation therapy at the London Health Sciences Centre. Pretreatment tumour biopsies were immunostained for B-cell lymphoma 2 (Bcl-2), Ki-67, and epidermal growth factor receptor (EGFR) to correlate biomarker expression with disease-free survival (DFS)., Results: Ki-67 expression was strongly associated with recurrence following radiation and independently predicted poor DFS (hazard ratio 4.86, 95% CI 1.58-15.00; p  =  .006). EGFR and Bcl-2 were not associated with a risk of recurrence., Conclusions: Ki-67 expression identified a subset of patients with increased risk of local recurrence after radiation therapy. Ki-67 expression can potentially guide improved personalized treatments for patients with early-stage glottic squamous cell carcinomas.

Laryngeal cancer is the most commonly diagnosed head and neck malignancy. Treatment of laryngeal tumors is dependent upon disease stage at diagnosis, and may involve surgery, radiation, chemotherapy or a combination of modalities. Regardless of tumor stage or treatment provided, quality of life (QOL) can be drastically affected. Voice-related outcomes are almost universally affected and can have a negative impact on overall QOL. Thus, treatment outcomes must extend beyond issues of oncological cure alone. Measures of voice and voice-related QOL following treatment for laryngeal cancer are important markers of treatment success. This article will broadly outline laryngeal cancer and its treatment, vocal rehabilitation, and provide insight into the various methods of assessing post-treatment voice and the influence of voice change on quality of life in these patients.

Objective: Radiation therapy (RT) and transoral laser microsurgery (TLM) are established treatments for early glottic squamous cell carcinoma (SCC). Similar oncologic outcomes have been reported with both modalities, leading physicians to consider other factors when making clinical recommendations. One such factor is voice-related quality of life. This investigation sought to characterize differences in self-reported voice outcomes in patients undergoing RT or TLM for the treatment of Tis or T1a glottic SCC., Methods: A retrospective cohort study was conducted of all individuals who received either RT or TLM for the treatment of Tis or T1a glottic SCC between 2004 and 2009 at the London Regional Cancer Program. The primary outcome measure was voice-related quality of life, as assessed by the Voice-Related Quality of Life questionnaire (V-RQOL). Secondary outcomes included local control, overall survival, and laryngectomy-free survival., Results: Fifty-seven patients were eligible for this study; 34 received RT and 23 received TLM. Forty (70.2%) of the 57 patients completed the V-RQOL. No statistically significant difference in total V-RQOL score was observed between the RT and TLM cohorts (p  =  .228). There was, however, a trend toward higher scores (ie, less voice disability) in the physical function domain of the V-RQOL for the RT group (90.0%) compared to the TLM group (80.2%) (p  =  .05). No significant differences were observed in recurrence or overall survival between the two groups., Conclusion: Both oncologic outcomes and self-rated voice-related quality of life are similar in patients treated with RT and TLM for early glottic carcinoma.

Introduction: Organ-preservation treatment approaches for advanced laryngeal cancer patients that use combination chemoradiotherapy result in cure rates similar to primary laryngectomy with postoperative radiotherapy. In the national VA Larynx Cancer Trial, successful organ preservation was associated with an overall improvement in quality of life but not in subjective speech compared with long-term laryngectomy survivors. As part of a Phase II clinical trial, a prospective study of speech and swallowing results was conducted to determine if larynx preservation is associated with improved voice and swallowing compared with results in patients who require salvage laryngectomy., Subjects: A total of 97 patients with advanced laryngeal cancer (46 Stage III, 51 Stage IV) were given a single course of induction chemotherapy (cisplatin 100 mg/m2 on Day 1 and 5-FU 1,000 mg/m2/day x 5 days), followed by assessment of response. Patients with less than 50% response underwent early salvage laryngectomy, and patients with 50% or better response underwent concurrent chemoradiation (72 Gy and cisplatin 100 mg/m2 on Days 1, 22, and 43), followed by two cycles of adjuvant chemotherapy (DDP/5-FU). Direct laryngoscopy and biopsy were performed 8 weeks after radiation therapy to determine final tumor response. Late salvage surgery was performed on patients with persistent or recurrent disease., Methods: Completed survey data on voice and swallowing utilizing the Voice-Related Quality of Life Measure (V-RQOL) and the List Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) were obtained from 56 patients who were alive and free of disease at the time of survey, with a minimum follow-up of 8 months. Comparisons were made between patients with an intact larynx (n = 37) vs. laryngectomy (n = 19), as well as early (n = 12) vs. late salvage laryngectomy (n = 7). Multivariate analysis was performed to determine factors predictive of voice and swallowing outcomes. Overall 3-year determinant survival was 87%, with median follow-up of 40 months., Results: Patients with an intact larynx demonstrated significantly higher (p = 0.02) mean V-RQOL scores (80.3) than did laryngectomy patients (65.4). This finding was consistent in the social-emotional (p = 0.007) and physical functioning domains (p = 0.03). No differences in V-RQOL scores were found in comparisons between early and late salvage laryngectomy. Multiple linear regression revealed that predictors of higher total V-RQOL scores include lower T stage (p = 0.03), organ preservation (p = 0.0007), and longer duration since treatment (p = 0.01). Understandability of speech was better in patients with an intact larynx (p = 0.001). Overall swallowing function was comparable between groups. Multiple logistic regression revealed that longer duration since treatment (p = 0.03, odds ratio = 1.1) and lower maximal mucositis grade (p = 0.03, odds ratio = 0.3) were predictive of higher likelihood of eating in public. Nutritional mode consisting of oral intake alone without nutritional supplements was achieved in 88.9% of patients with an intact larynx compared with 64.3% of laryngectomees (p = 0.09)., Conclusions: Voice-related quality of life is better in patients after chemoradiation therapy compared with salvage laryngectomy. Earlier salvage, although known to be associated with fewer surgical complications, did not result in improved voice; however, the number of patients analyzed is small. Overall swallowing function is good in all patients; however, patients with an intact larynx are more likely to obtain nutrition with oral intake alone without supplements. Such measures of function and quality of life are important endpoints to help judge overall effectiveness as newer, more aggressive treatment protocols with added toxicities are developed and evaluated.