Laser Vs Radiation in early-stage laryngeal SCC with Anterior commisural involvement

1. Radiotherapy versus endolaryngeal
surgery (with laser) for early laryngeal
SCC with Anterior commisural
involvement
Dr. Vijay .P. Raturi
Dept of Radiation Oncology,
Kokilaben Dhirubhai Ambani Hospital

3. After Trans-oral Laser SurgeryBefore Transoral Laser Surgery

4. • Diificult for anterior tumours
• Possibility of Residual if visualisation not proper
• Learning curve
• How easy is it to operate on anterior commissure where the third dimension
is thyroid cartilage
• Both cords are detached, still the surgeon says the patient have a better
voice quality
Visualisation of anterior commissure

6. • Notably, the author(Blacnh JL et al) also found recurrence after TLM of the
anterior commissure to be significantly related to the learning curve of the
surgeon.
• The ELS type VI resection was introduced in 2007 in a revision of the original
classification (type I–V) specifically to deal with resections of the AC
Remacle M, Van Haverbeke C, Eckel H, Bradley P, Chevalier D, Djukic V, et al. Proposal for revision of the EuropeanLaryngological Society
classification of endoscopic cordectomies.Eur ArchOtorhinolaryngol. 2007;264(5):499–504.
Blanch JL, Vilaseca I, Caballero M, Moragas M, Berenguer J, Bernal-Sprekelsen M. Outcome of transoral laser microsurgery for T2-T3 tumors
growing in the laryngeal anterior commissure. Head Neck. 2011;33(9):1252–9.
Anterior Commissure Involvement

7. To address the issues of response:
• What should be the primary end points for response?
• How does surgery / Radiation affect that response?
• What are the types of surgery?
• Dose specific anatomic features has inferior outcome in surgery?

8. Basic Anatomy of Glottis

9. AJCC 8th Edition TNM Glottic Cancer Staging

10. What should be the primary end points for response?

11. How safe is TLS for T2 Glottic cancer
• Peretti highlights that it is important to differentiate between tumors located in
the AC in the horizontal plane and tumors extending from the AC in the vertical
plane to the supra- and/or subglottis
• Peretti argues that tumors with pure horizontal spread in the AC form a good
indication for TLM. The risk of poorer local control arises from tumors with
vertical extension from the AC as these tumors have a close relationship with the
underlying visceral spaces (pre-epiglottic space and subglottis) and carry a risk of
microscopic spread into these areas.
• In support of this reasoning in which he highlights this important distinction, he
found a negative impact on local control only for those tumors crossing the
anterior commissure in the vertical plane
Peretti G, Piazza C, Mora F, Garofolo S, Guastini L. Reasonable limits for transoral laser
microsurgery in laryngeal cancer. CurrOpin Otolaryngol Head Neck Surg. 2016;24(2):135–9.Very
clear and conscise discussion on the limits of TLM

12. • In a large study from 2009 published by Ršdel (463 T1–T2), analysis showed
involvement of the AC to be associated with decreased local control in T1a
and T1b but not in T2 tumors although survival was not affected.
• The author (Rsdel) argues that TLM is still an effective treatment for tumors
located in the AC as most of the recurrent tumors could still be treated with
further TLM procedures.
• Conversely, Hakeem found local control significantly lower in T2 patients
with AC involvement but not in T1a or T1b, although there was a trend for
poorer local control in T1b tumors in his study of 296 T1–T2 patients.
• Hoffman found patients with AC involvement to have lower local control,
laryngeal preservation rate, and disease-specific survival in her study of 201
patients with Tis–T2 glottic carcinoma.
Anterior Commisure involvement

13. For T1 tumours, the five-year survival was 91.7% following radiotherapy and
100% following surgery, There were no significant differences in survival
between the two groups.

14. Local Control after Radiotherapy
Mendenhall WM et al. Management of T1-T2 Glottic Carcinomas. Cancer
2004; 100 (9):1786-1792.

15. • The two main treatment modalities for early glottic carcinomas (Tis–T2) are organ sparing surgery in the form of
transoral laser microsurgery (TLM) or open partial laryngectomy(OPL) and radiotherapy (RT).
• They are all used both in primary treatment and in the treatment of recurrent disease.
• There is no formal proof that one treatment is more effective than the other including a recent Cochrane analysis.
• Although there is evidence that TLM as a primary treatment modality is associated with a higher laryngeal preservation
rate than RT in early glottic carcinoma [A–D], and though it was not randomized, the study by Mahler was well
controlled[A].
• Therefore, treatment strategy depends on surgeon and patient preference and varies between countries, institutions,
and individual surgeons
A>. Mahler V, Boysen M, Brondbo K. Radiotherapy or CO(2) laser surgery as treatment of T(1a) glottic carcinoma? Eur Arch Otorhinolaryngol.
2010;267(5):743–50.
B>. Schrijvers ML, van Riel EL, Langendijk JA, Dikkers FG, Schuuring E, van derWal JE, et al. Higher laryngeal preservation rate after CO2 laser surgery compared
with radiotherapy in T1a glottic laryngeal carcinoma. Head Neck. 2009;31(6):759–64.
C>. Abdurehim Y, Hua Z, Yasin Y, Xukurhan A, Imam I, Yuqin F. Transoral laser surgery versus radiotherapy: systematic review and meta-analysis for treatment
options of T1a glottic cancer. Head Neck. 2012;34(1):23–33.
D>. Low TH, Yeh D, Zhang T, Araslanova R, Hammond JA, Palma D,et al. Evaluating organ preservation outcome as treatment endpoint for T1aN0 glottic cancer.
Laryngoscope. 2016

16. • The anterior commissure is a risk factor if involved in the cranio-
caudal plane, and reduced vocal fold mobility is a risk factor when this
is due to arytenoid involvement.
• The best voice results area achieved when the anterior commissure
can be left intact along with part of the vocal fold muscle although
even in larger resections, patient self-reported voice handicap is still
limited.

17. • In TLM of early glottic carcinoma, it is generally accepted that a proportion of
patients with positive margins will not develop a recurrence, and the
relationship between resection margin status and relapse rate is still unclear
• At the glottic level, most authors consider 1–2 mm as an adequate margin
although some authors have suggested that margins less than 0.5 mm may be
enough in Tis–T1 carcinoma as the ligament still forms a barrier to tumor
spread in early lesions
• The average recurrence rate reported by authors adopting a wait and see
attitude appears to result in a slightly higher chance of recurrence (mean of
13.5%), as opposed to that of those who choose the more aggressive
approach of re-treating most patients (mean of 9%).
Resection Margins

18. • At the author’s institution, we agree with this reasoning although we adopt a more
aggressive policy in positive deep margins, especially in larger T1 and T2 tumors as the
chance of a submucosal recurrence is larger in these cases.
• As for second-look microlaryngoscopy, the recent ELS recommendations on follow-up after
treatment for laryngeal cancer take the position that a second-look microlaryngoscopy is
mandatory in case of positive margins and can be indicated in various other situations such as
close margins, granulomas, web formation, or involvement of certain laryngeal subsites such
as the AC, the laryngeal ventricle, and the subglottis
Fraction of cases in literature receiving re-treatment nd having a positive or inadequate surgical margins
after TLM for early glottic carcinomas and the association with recurrence rates and mean recurrence rate

19. What are the implications on functional
outcome ?
• Voice quality
• Swallowing compromise
• Airway related complications

20. Voice quality ?
• Does voice quality change after surgery / Radiotherapy?
• Evidence of voice analysis after radiotherapy /Surgery ? Favoring any
modality?
• Comparative analysis of different voice parameters ? Surgery / RT
• Difference in voice quality with Types of surgery ? Ant commissural
involvement?

21. • All patients were studied with videolaryngostroboscopy, voice analysis by narrow
spectrogram and vocal parameters (Jitter, Shimmer, noise/harmonic ratio, and
diplophonia).
• Videolaryngostroboscopy showed severe glottic inadequacy in 25% of cases
treated with radiation and insufficient compensation ‘ventricular band’ or ‘with
arytenoid hyperadduction’ in 65% of cases after surgery. Severe dysphonia on the
electro-acoustic analysis of voice was observed in 25% of cases after radiation and
70% after laser (pB/0.001). Fundamental frequency and vocal parameters showed
more favourable results in the radiation group (pB/0.001).
• Voice assessment showed better results after radiotherapy compared with laser
cordectomy

22. Vocal Parameter

23. • Jitter (absolute) is the cycle-to-cycle variation of fundamental frequency.
• Shimmer (dB) is expressed as the variability of the peak- to-peak amplitude
in decibels, i.e. the average absolute base-10 logarithm of the difference
between the amplitudes of consecutive periods, multiplied by 20
• HNR is a measure that quantifies the amount of additive noise in the voice
signal
• The fundamental frequency, often referred to simply as the fundamental, is
defined as the lowest frequency of a periodic waveform

24. Voice quality after radiotherapy and laser cordectomy

25. • 30 early stages glottic cancer cases were exclusively treated by TLM and
included into this study
• 29 (96.7%) patients were male and 1 (3.3%) were female. The mean age
was 61.1 years (± 9 years). 96.7% tumours is T1 and 3.3% for T2.
• The presence of intraoperative complications Bleeding was low, affecting
only 2 patients. Immediate postoperative complications (bleeding)
occurred in 1 patients (3.3%), whereas delayed complications affected 3.3%
of patients (1 laryngeal synechia), without any of them being fatal.
• 30% of patients had normal voices and a further 63.3% had only mild or
moderate voice change. At their last follow up, no patients assessed had
any difficulty respiratory or swallowing to their treatment for glottic cancer.

26. • When looking at functional outcomes, the three main functions the
larynx potentially affected by any treatment are airway, swallowing,
and voice. Of these, vocal function is the most frequently affected.
• Additionally, other acute or chronic complications induced by the
operation as well as overall quality of life need to be considered.
Functional outcome of Trans-oral laser surgery

27. Change on Voice Parameter after TLS
• Many studies have demonstrated that the quality of voice after TML is related to the extent of the resection
• Type I–III resections, where at least some of the vocal muscle and the contralateral side of the anterior
commissure are preserved, result in very acceptable voices with only mild dysphonia and low voice handicap
reported by patients themselves
• Grades of dysphonia for these resections vary from less than 1 to 1.5 on the GRBAS scale (grade roughness
breathiness asthenia strain) for perceptual rating corresponding to mild dysphonia . Voice handicap index (VHI)
scores are very close to normal ranging from 19 to 28 where 120 is the maximal score and scores of 15 or under
are considered normal.
• Vilaseca found that on average, voice quality after TLM was worse than that in normal controls for every
resection type but that in the case of type I resection, perceptual analysis showed it was normal in a majority
(66%) of patients and as high as 55% even in type III resections
• Wider excisions (type IV–VI) including total resection of the vocal fold muscle and/or the AC will lead to more
severe forms of dysphonia in most patients.

28. • Bahannan found that type I–III resections result in a significantly better
voice outcome than type IV and V resections in 62 patients with Tis–T2
lesions.
• Fink reported a similar outcome in 49 patients with Tis–T1a lesions.
Patients undergoing type I–III resections experienced on average an
improvement in the VHI from 39 to 23 whereas patients undergoing a
more extended resection had an increase in the VHI from 33 to 39
• Mendelsohn found a postoperative VHI of 24 in 13 patients undergoing
extended resections (type III–VI) with a mean grade of 2 (moderate
dysphonia)
• The same author (Mendelsohn) also published one of the only reports
specifically on voice outcome after resections of the AC which showed a
VHI of 37 and a mean grade of 2.1 (moderate dysphonia) in these
patients
Change In Voice Parameter after TLS

29. Voice Handicap Index (VHI)

30. Swallowing function after TLS
• In extended lesions, sporadic cases of severe long-term dysphagia are reported
• In 2004, Bernal-Sprekelsen published a series of 45 T2 glottic carcinomas treated with
TLM. The average duration of nasogastric feeding tube dependence was 0.18 days. Out of
his 45 patients, only 1 underwent percutaneous endoscopic gastrostomy placement,
tracheotomy, and finally, total laryngectomy for swallowing problems
• Two recent publications have contributed to detailing of swallowing after TLM. In a series
of 89 type V resections, Peretti found favorable swallowing outcomes. In the MDADI
(M.D. Anderson dysphagia inventory), self-evaluation questionnaire of swallowing
patients scored an average of 96 out of a maximum of 100. Only 2 and 4% of patients
showed tracheal aspiration on VEES (video endoscopic evaluation of swallowing) and VFS
(videofluoroscopy) examinations

31. Other functional outcome
• Does swallowing parameters affected by Surgery / RT equally?
• Is there any airway compromise in surgery group?
• Are the long term sequela after surgery / RT equal ?

32. Airway and other complication after TLS
• The upper airway and other complications are rare after TLM. The large series
described under the oncological outcomes section reported the following
complications: in 719 patients, Motta reported subcutaneous emphysema from
penetration of the cricothyroid membrane in 5% of patients, which necessitated
tracheotomy in four. An additional four patients required tracheotomy from oedema
after cauterization bringing the total amount of tracheotomies to 1%. Bleeding
resolved by endoscopic revision occurred in 1.6% of patients.
• In 595 patients, Peretti reported only major bleeding as a complication in 0.4% of
patients in which endoscopic revision was sufficient to solve the problem.
• In 285 patients, Eckel reported one patient who developed a glottic stenosis and
required further open surgery to restore an adequate airway. No other complications
were seen.

33. • Among 55 patient postoperative bleeding was the most commonly
seen complication. It appeared in 34 of them (62%).
• In 23 cases pain and mild laryngeal oedema were observed.
• Eight patients needed revision procedures: four due to granulation
tissue formation, two due to adhesion and another two due to
laryngocele.
• Eight patients needed revision procedures: four due to granulation
tissue formation, two due to adhesion and another two due to
laryngocele.

34. • Overall, a total of 13 published studies were included in our study, with 368
patients in the RT group and 440 patients in the LS group, respectively.
• No significant differences in Voice Handicap Index (VHI), jitter and shimmer
were found between RT and endoscopic LS among patients with Tis-
T1N0M0 glottic carcinoma and T1aN0M0 laryngeal cancer.
• However, the acoustic voice analysis parameters of Fo values were
significantly lower in RT group than that in LS group.
• Conclusion: The results from this meta-analysis support that the LS has
more advantages than RT in terms of voice quality. However, more studies
on voice outcome need to validate our findings.

35. Type of Cordectomy
TYPE 1: Sub-epithelial cordectomy TYPE 2: Sub-ligament Cordectomy

36. TYPE 3: Transmuscular Cordectomy TYPE 4: Total or Complete Cordectomy

37. TYPE Va: Extended Cordectomy
encompassing the contralateral vocal fold
TYPE Vb: extedned Cordectomy encompassing
the arytenoids
TYPE VC: Extended cordectomy
encompassing the ventricular fold
TYPE VD : Extended cordectomy encompassing
Subglottis

38. Take home message
• With advanced surgical techniques increased in uncomplicated surgery for
early larynx carcinoma.
• Still functional outcome is debatable
• With anterior commissural involvement both functional outcome and
surgical results may be questioned.
• Simple radiotherapy techniques are sufficient enough to cure this disease.
• RT strongly recommended in ant commissure disease.

39. Thank You