Laryngeal Cancer (Cancer of the larynx)

Cancer of the larynx

Anatomy Pathology General Prevention Epidemiology Incidence Etiology Associated conditions Diagnosis Signs and Symptoms Tests Differential Diagnosis Clinical Findings T STAGE: Laryngeal Cancer Treatment L Diet L Activity L Medication L Surgery Complications Prognosis References

Samuel W. Beenken, MD, & Marshall M. Urist, MD, Roy R. Casiano, MD Most common cancer representing <1% of all malignant lesions. Squamous cell carcinomas constitute 5-98% of all malignant neoplasms of the larynx. Less than 2% of all carcinomas At the time of diagnosis, 62% will have local disease, 26% regional disease, and 8% distant disease in the lungs, liver, and/or bone. No racial predilection System(s) Affected: Pulmonary

 Synonym(s): Cancer of larynx

Anatomy
The larynx is composed of three anatomic subsites. The supraglottic larynx extends from the epiglottis superiorly to the false cords inferiorly. Sites within the supraglottic larynx include the epiglottis (both lingual and laryngeal surfaces), aryepiglottic folds, arytenoids, and false cords. The glottic larynx consists of the true vocal cords (including the anterior commissure) superiorly and tissues within 5 mm of the inferior surface of the true vocal cords inferiorly. The subglottic larynx extends from the glottis superiorly to the inferior border of the cricoid cartilage inferiorly. Subglottic cancers are uncommon, accounting for less than 1% of all laryngeal cancers. Subglottic extension of a glottic cancer is more common.

Pathology
Squamous cell carcinoma of the supraglottic larynx accounts for 35% of laryngeal cancers. Fifty percent of these patients will present with cervical lymph node metastases. Lymphatic channels drain to the upper, mid, and lower jugular nodes (levels II, III, and IV). Local spread of cancer is usually in a superior or lateral direction. Inferior spread to the anterior commissure is less common. Cancer of the glottic larynx accounts for nearly Laryngeal Cancer news 65% of laryngeal cancers. It tends to be well differentiated, to grow slowly, and to NJ Cancer Researcher Recognized for metastasize late. Because the true cords have Ten Minutes That Could Save Your Life very limited lymphatic drainage, cervical Burning incense increases risk of respiratory lymph node metastases occur in only 10% of Infection contributes to the high rates cases. Cervical lymph node metastases usually Laryngeal Cancer and Tumor Staging occur when the cancer infiltrates beyond the Prevalence and Incidence of Larynx Cancer limits of the true cord. Submucosal extension occurs early and can lead to involvement of the Statistics and prognosis for cancer anterior commissure and the contralateral Acid reflux may raise risk of cancer vocal cord. The cancer can extend laterally, Single hit chemo guides therapy for resulting in cartilage destruction, or superiorly, Treatment method improves survival for with involvement of the false vocal cords and aryepiglottic folds (transglottic carcinoma). Subglottic extension can also occur. Subglottic cancers or subglottic extensions of a glottic cancer are associated with a high incidence of cervical lymph node metastases. Lymphatics from the subglottic larynx drain to the mid and lower jugular lymph nodes (levels III and IV) and to the prelaryngeal (cricothyroid or delphian) node. Subsequently, the pretracheal and paratracheal lymph nodes can be involved.

General Prevention
Indirect laryngoscopy for patients with persistent hoarseness lasting beyond 1-2 weeks

 Cessation of smoking and/or alcohol abuse

Epidemiology
Predominant age: 1. Median age of occurrence in the sixth and seventh decades 2. Less than 1% of laryngeal cancers arise in patients younger than 30 years of age. 3. Very rare in young patients, in general Predominant sex: Male > female (5:1), however, increasing incidence in women who smoke

Incidence
5 in 100,000 (12,500 new cases per year)

Etiology
Smoking Alcohol abuse

Associated conditions
>10% of patients may have a synchronous squamous cell carcinoma in the lower or upper aerodigestive tract, most notably in the esophagus or lungs.

Diagnosis
Signs and Symptoms
Persistent hoarseness in an elderly or middle-aged cigarette smoker Dyspnea and stridor Ipsilateral otalgia Dysphagia Odynophagia Chronic cough Hemoptysis Weight loss owing to poor nutrition Halitosis owing to tumor necrosis Mass in the neck from metastatic lymph node Laryngeal tenderness owing to tumor necrosis or suppuration Lump in the neck

 Broadening of the larynx on palpation with loss of crepitation Tenderness of the larynx Fullness of the cricothyroid membrane

Tests
Lab Liver function studies to rule out metastatic disease Imaging Computed tomography (CT) or magnetic resonance imaging if chest and liver or brain metastasis suspected Bone scan if bone metastasis suspected Screening chest radiograph to rule out metastatic disease Diagnostic Procedures/Surgery Laryngoscopy: Fungating, friable tumor with heaped-up edges and granular appearance, with multiple areas of central necrosis and exudate surrounding areas of hyperemia Indirect and/or direct laryngoscopy and biopsy to determine stage of disease as well as histologic confirmation

Differential Diagnosis
Acute or chronic laryngitis Benign vocal cord lesions such as polyps, nodules, and papillomas Tuberculosis or fungal infection of the larynx

Clinical Findings
The initial presenting symptoms of cancer of the larynx depend upon the site involved. Supraglottic cancers tend to present late with symptoms of dysphagia, odynophagia, hemoptysis, or referred otalgia. Stridor and hoarseness are late findings. Palpable cervical lymphadenopathy is a common presenting sign. Glottic cancers often present early with hoarseness, and palpable lymphadenopathy is uncommon. Late symptoms include dysphagia, odynophagia, stridor, or cough. Subglottic cancer presents with dyspnea, stridor, or palpable cervical lymphadenopathy. T STAGE: LARYNGEAL CANCER Supraglottis T1 Tumor limited to one subsite of the supraglottis with normal vocal cord mobility T2 Tumor invades more than one subsite of the supraglottis or glottis, with normal vocal cord mobility T3 Tumor limited to the larynx with vocal cord fixation and/or invades the postcricoid area, medial wall of the piriform sinus, or pre-epiglottic tissues T4 Tumor invades through the thyroid cartilage and/or extends to other tissues beyond the larynx (eg, to the oropharynx or soft tissues of the neck) Glottis T1 Tumor limited to the vocal cord(s) (may involve anterior or posterior commissures) with normal mobility T1a: Tumor limited to one vocal cord T1b:Tumor involves both vocal cords T2

Tumor extends to the supraglottis and/or subglottis, and/or with impaired vocal cord mobility T3 Tumor limited to the larynx with vocal cord fixation T4 Tumor invades through the thyroid cartilage and/or extends to other tissues beyond the larynx (eg, to the oropharynx or soft tissues of the neck) Subglottis T1 Tumor limited to the subglottis T2 Tumor extends to the vocal cord(s) with normal or impaired vocal cord mobility T3 Tumor limited to the larynx with vocal cord fixation T4 Tumor invades through the thyroid cartilage and/or extends to other tissues beyond the larynx (eg, to the oropharynx or soft tissues of the neck)

Treatment
T1 and T2 cancers of the supraglottic and glottic larynx respond well to radiation therapy. Survival rates are similar to those achieved with surgery, including laser excision, but without the attendant morbidity. Elective radiation therapy to the neck is given to patients with supraglottic carcinomas. T3 and T4 cancers of the supraglottic and glottic larynx are treated with a combination of cisplatin-based chemotherapy and radiation therapy in an effort to avoid the morbidity associated with total laryngectomy. Patients are reevaluated following initial chemotherapy and radiation therapy. If there is complete disappearance of the cancer and biopsies are negative, surgery is avoided. In this way, nearly two-thirds of patients can be spared laryngectomy. Survival rates for patients receiving initial chemotherapy and radiation therapy are the same as those for patients receiving total laryngectomy. Surgical options for supraglottic and glottic cancer include partial laryngectomy or total laryngectomy. Partial laryngectomy is appropriate for patients with T1 and T2 cancers. Vertical partial laryngectomy removes the ipsilateral vocal cord and overlying laryngeal cartilage. The procedure can be extended superiorly to include the ipsilateral false cord or posteriorly to include the ipsilateral arytenoid cartilage. It is an appropriate procedure for patients with reduced cord mobility due to cancer bulk but not for patients with reduced cord mobility due to invasion of the intrinsic musculature. Horizontal partial laryngectomy is indicated for patients with cancers arising above the level of the true cords. All patients will have some degree of aspiration following this procedure, but careful patient selection can minimize the long-term consequences. Total laryngectomy is appropriate therapy for some patients with T3 laryngeal cancers and for most patients with T4 cancers. In this situation, wide field laryngectomy includes removal of the bilateral level II, III, and IV cervical lymph nodes. Ipsilateral thyroid lobectomy is performed to facilitate paratracheal lymph node dissection. The presence of cervical lymph node metastases is an indication for radical or modified neck dissection. Elective neck dissection or radiation therapy is not indicated for T1 and T2 glottic cancers but is indicated for all supraglottic cancers and for T3 and T4 glottic cancers. If the primary cancer is treated by surgery, an elective neck dissection is appropriate unless adjuvant radiation therapy to the primary cancer site is planned. In that case, elective neck radiation therapy can be given and the neck dissection deferred. If the primary cancer is treated with radiation therapy, elective neck radiation therapy is appropriate and operative dissection can be deferred.

Diet
Nasogastric or gastrostomy feeding may be necessary if tumor involves esophageal inlet.

 No special diet otherwise

Activity
Patient may remain fully active unless he or she is debilitated from more advanced disease and/or greater degree of surgery.

Medication (Drugs)
Narcotics may be necessary for pain control during treatment for mucositis secondary to radiation therapy. Nystatin mouth rinses for oral thrush

Surgery
Tracheotomy may be necessary if tumor is large enough to cause upper airway obstruction Early disease may be treatable by either radiation therapy or laser cordectomy on an outpatient basis. Ninety percent cure rates are the rule. More advanced disease needs inpatient care necessitating partial or total laryngectomy and postoperative radiation therapy 4-5 weeks after surgery, depending on the stage of disease. The Larynx - laryngeal cancers treatment Because of the prominent role the larynx plays in communication, swallowing, respiration, protection of the lower airway, and therefore, quality of life, the treatment of cancer of the larynx presents formidable dilemmas regarding the functional consequences of treatment in addition to the intrinsic threat to life posed by these cancers. Unique to this particular site of head and neck cancer, quality-oflife issues have been incorporated into treatment decision making more extensively than for other cancer sites. Cancer of the larynx is generally diagnosed at an earlier stage than are other head and neck sites, primarily owing to the early manifestation of symptoms. As a result, cure rates are generally higher than for other sites. Read more

Complications
Temporary odynophagia or dysphagia secondary to mucositis and/or thrush during radiation therapy Persistent hoarseness despite adequate treatment, necessitating further adjunctive procedures and/or speech therapy Tracheostomal stenosis requiring stenting with laryngectomy tubes or further surgery Dysphagia secondary to upper esophageal stricture after total laryngectomy, necessitating dilatation Aspiration after partial laryngectomy, necessitating complete laryngectomy or tracheotomy Inability to decannulate after partial laryngectomy because of laryngeal stenosis and/or aspiration

 Radiation-induced chondronecrosis, which mimics tumor recurrence Radiation edema, necessitating emergent tracheotomy

Prognosis
Five-year survival rates for supraglottic cancer with appropriate treatment are as follows: stage I, 9095%; stage II, 75-80%; stage III, 50%; stage IV, 20-40%. Five-year survival rates for glottic cancer with appropriate treatment are as follows: stage I, 80-95%; stage II, 70-80%; stage III, 50-70%; stage IV, 20-50%.

References
Forastiere AA et al: Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349:2091. Pubmed: 14645636 Hinerman RW et al: Carcinoma of the supraglottic larynx: treatment results with radiotherapy alone or with planned neck dissection. Head Neck 2002;24:456. Pubmed: 12001076 Hinerman RW et al: Early laryngeal cancer. Curr Treat Options Oncol 2002;3:3. Pubmed: 12057082 Mendenhall WM et al: Management of T1-T2 glottic carcinomas. Cancer 2004;100:1786. Pubmed: 15112257 Ariyan S. Cancer of the Head and Neck. St. Louis, MO: Mosby; 1987. Cummings CW, et al., eds. Otolaryngology Head and Neck Surgery. Vol 3. 3rd ed. New York, NY: Mosby; 1998. Suen JY, Myers EN. Cancer of the Head and Neck. 3rd ed. Philadelphia, PA: WB Saunders; 1996.

Read more: Laryngeal cancer - Cancer of the larynx- Introduction, Etiology and Pathology, Symptoms, Signs, Diagnosis and treatment http://www.health.am/cr/laryngeal-cancer/#16#ixzz2g0oF5Jnc

Cancer of the Larynx

(Laryngeal Cancer, Vocal Cord Cancer, Cancer of the Glottis, Throat Cancer) In this factsheet: The Facts on Cancer of the Larynx Causes of Cancer of the Larynx Symptoms and Complications of Cancer of the Larynx Diagnosing Cancer of the Larynx Treating and Preventing Cancer of the Larynx

The Facts on Cancer of the Larynx

The larynx, also called the voice box or Adam's apple, is the part of the body that allows humans to produce sounds and speech. The larynx contains the vocal cords (glottis), which vibrate when air passes through. The epiglottis is a small flap of cartilage found at the top of the larynx. The epiglottis protects the airways by keeping food and saliva from going down the trachea (the "windpipe" tube that leads to the lungs). Cancer of the larynx can occur on the glottis (most laryngeal cancers are there), the supraglottis (the area above the vocal cords that includes the epiglottis), or the subglottis (the area that connects the larynx to the trachea). Cancer of the larynx affects more men then women, although more women are developing it today due to an increase in smoking in the female population.

Causes of Cancer of the Larynx

Although the exact cause of cancer is unknown, some known risk factors for cancer of the larynx include: smoking: The risk of laryngeal cancer increases up to 30 times for smokers. The heavier the person smokes, the higher the risk. Second-hand smoke is also considered a hazard. alcohol: Heavy drinkers more than double their risk for this type of cancer, and combining smoking with alcohol can increase the risks even more than either drinking or smoking alone. gastroesophageal reflux disease (GERD): In GERD, the stomach acid backs up into the esophagus, causing a burning pain. Although not definitively proven, researchers have found that irritation from longstanding GERD is related to higher chances of laryngeal cancer. poor nutrition: Many people who abuse alcohol also have poor nutritional habits, but some research also suggests that not getting enough vitamins might be a risk factor. human papillomavirus (HPV): The virus that can cause genital warts can also develop into certain cancers. Mothers may pass the virus on to their children when they're born. It settles in the larynx, developing into growths called laryngeal papillomas later on in life. These growths may develop into cancer. race: Laryngeal cancer is found twice as often among people of African descent than among Caucasians. gender: More men than women are diagnosed with cancer of the larynx. age: This type of cancer is usually detected in people between 50 and 75 years old. weakened immune system: People with weak immune systems (due to diseases such as AIDS or medications that lower immunity to viruses) are more susceptible to laryngeal cancer. toxic exposure: These risk factors include being exposed to wood dust, asbestos, or many types of chemicals that can increase the chances of cancer. voice overuse: People who use their voices a lot, such as singers, may develop polyps (lumps of tissue) that can become cancerous if not removed.

Symptoms and Complications of Cancer of the Larynx

The symptoms of laryngeal cancer depend on where in the larynx the tumour is located. Cancer on the vocal cords can often be detected early because the main symptom is hoarseness. Most people go hoarse from time to time, but if the hoarseness doesn't go away in two weeks, it should be checked. Symptoms that the cancer has spread or is occurring in another part of the larynx include: a cough that doesn't go away persistent sore throat breathing difficulties, or feeling that something is catching in the throat ear pain (pain from deep in the throat can be felt in the ear) a lump or mass in the neck or throat coughing up of blood

There are a few complications that can result from laryngeal cancer. Airway obstruction: Any tumour or swelling in the airway can cause a blockage, making breathing difficult. If treatment involves total removal of the larynx, a tracheostomy (surgery to create an artificial airway in the trachea) is then performed to improve breathing. Disfigurement: Removing the tumour and surrounding tissue could leave some disfigurement of the throat and neck. Muscles might be removed as well, making neck movement more difficult. If a tracheostomy was performed, the stoma (opening in the throat) is sometimes permanent. Difficulty eating: After surgery, it may become difficult to swallow certain consistencies of food. Those undergoing radiotherapy may have trouble swallowing or even chewing. Chemotherapy can cause nausea and vomiting. A good, healthy diet is vital when recuperating from cancer, so it's important that adequate nutrition be maintained throughout the treatment. Cancer spread: It's possible that the cancer may spread to other areas of the body. Voice loss: Treatment that involves removing the entire larynx makes normal speech impossible. In this case, alternate methods of speaking need to be learned. These are: esophageal speech: This is the most basic form of alternate speech, which is done by swallowing air and creating sound by expelling it. tracheoesophageal puncture (TEP): A small one-way valve is placed between the trachea and esophagus. By taking in air through their stoma into the lungs, then covering their stoma (from the tracheostomy), sounds can be made through the mouth. electrolarynx: When you hold this electronic device next to the skin of the throat or the corner of the mouth, it produces a mechanical voice. Muscle movements stimulate the machine to make sounds. While these new methods of speech are being learned, other ways of communicating will be needed. This might mean keeping a "magic slate" or pad and pencils easily available. It's important to plan ahead to help avoid frustration after surgery.

Diagnosing Cancer of the Larynx

If cancer is suspected, your doctor will first take a medical history, including information about smoking and alcohol use. It's important to mention past use or exposure even if there's none at the present. After a physical exam, the following tests may be performed:

 laryngoscopy: A flexible tube (fiberoptic scope) is used to check for tumours or polyps in the larynx, mouth, tongue, and neck. computed tomography(CT): A type of scan that allows the doctors to see any abnormalities (e.g., imaging of the neck). magnetic resonance imaging (MRI): Another type of scan that can detect abnormalities in the neck. chest X-ray: This test checks for any tumours that may have spread into the lungs. positron emission tomography (PET) scan: This test can help define the extent of cancer in the neck, as well as identify any distant areas of spread. biopsy: Removal of a small section of tumour tissue to examine any signs of cancer. The tissue is taken either during an endoscopy or through a fine needle that is inserted into the neck (local freezing or general anaesthesia may be used to make the procedure more comfortable). Diagnosis also includes determining the stage of the cancer in order to identify how advanced it is. stage 0: The cancer has not invaded the tissue and can be removed from the vocal cords without removing any tissue. stages 1 and 2: The cancer has invaded the local tissue but is still in the body area where it started. stages 3 and 4: The cancer has invaded beyond the local tissue and has probably spread (metastasis) to local lymph nodes, or even more distant sites elsewhere in the body. recurrent: The cancer has returned after initial treatment.

Treating and Preventing Cancer of the Larynx

Like most cancers, treatment for laryngeal cancer involves surgery, radiotherapy, chemotherapy, or a combination of treatments. The decision about what type of therapy to use is made according to how advanced the cancer is (i.e., the stage) and exactly where it is located. Early-stage cancer of the larynx can often be treated with radiation alone. Radiotherapy is the preferred method whenever possible, because it usually doesn't affect the quality of the voice and side effects are most often temporary. The side effects to radiation can include: sensitive mouth and gums sores in the mouth dry mouth sore throat voice changes red, dry skin change in or loss of sense of taste or smell

Surgery can involve removing the whole larynx and surrounding tissues or just part of the larynx, depending on how far the cancer has spread. With partial removal (laryngectomy), you will often be able to eat and breathe as you did before the surgery, after healing is complete. You will probably have a temporary tracheostomy while the throat

repairs, but the stoma will be allowed to close up and breathing will return to normal. Your voice quality may change but you will be able to speak. If you need to undergo a total laryngectomy where the voice box is completely removed, you will be left with a tracheostomy in order to breathe. This tracheostomy is permanent. Finally, chemotherapy may be needed if the cancer has spread. Chemotherapy is also used to "sensitize" the area for radiation in cases of advanced tumours that are still thought to be treatable. Because chemotherapy circulates throughout the body, more of the body systems are affected by the treatment. Side effects from chemotherapy include: nausea and vomiting possible hair loss fatigue diarrhea mouth sores increased risk of infections damage to hearing

The five-year survival rate for laryngeal cancer that's detected early is usually 80% or more. Most recurrences of cancer happen within the first 2 or 3 years of treatment. Follow-up procedures usually involve monthly checkups for the first year and then every few months thereafter. Unfortunately, because the very same risk factors that might have caused the first tumour may also have caused other damage, the chances of a second tumour developing (often in the head, neck, or lung) can be as high as 25%. Many risk factors for cancer of the larynx are known, the most common of these being smoking and heavy alcohol use. Many cases of cancer could be prevented by avoiding these known causes. Other ways to reduce risk include: using respirators when in industrial areas with cancer-causing chemicals getting treatment for GERD eating a healthy and balanced diet

Laser Treatment for Laryngeal Cancer: Good Results-and Complex Questions

From: ENT Today, May 2009
by Thomas R. Collins Management of laryngeal cancer with a laser has grown from a treatment strategy once derided as malpractice to a cornerstone that has become replete with complex considerations for laryngeal surgeons, according to panelists who discussed the history and the future of the use of the laser to treat throat cancer. But it is a strategy that has proven to be oncologically safe, as evidenced by multiple studies discussed by the group in a series of presentations that together formed a kind of tribute to the technology and

those who have honed it. Since the first treatment of a lesion on the larynx-a procedure first described in 1886, which involved a mirror and topical anesthesia with propane-the process has been highly fine-tuned, but it now presents more questions for the surgeons. Every advancement since the direct laryngoscope in the meantime has historically enhanced surgical precision, said James Burns, MD, the moderator of the panel. So from about the 1920s on, improvements in general anesthetics, the introduction of the operating microscope in the 1960s, and the expanding use of lasers from the 1970s on have contributed to current treatment strategies of larynx cancer. So the question becomes: Is endoscopic management of laryngeal cancer oncologically safe? Should the procedure be total or partial? How much of a role should preservation of voice function play and how should the prospects for voice function be analyzed? What is the role of imaging, and how should the patient be staged? What should be done surgically and what should be attempted through radiation therapy? The devil is in the details a bit here, said Dr. Burns, a laryngeal surgeon at the Center for Laryngeal Surgery and Voice Rehabilitation at Massachusetts General Hospital and an Assistant Professor in the Department of Surgery at Harvard Medical School. Gady Har-El, MD, Chairman of the Department of Otolaryngology-Head and Neck Surgery at Lenox Hill Hospital in New York, emphasized that there might be too much of an attempt at times to put off surgery and try to preserve voice function with radiation, when immediate surgery might yield good results as well. If you look at statistics, including those from the American Cancer Society, you will see that there's actually no improvement in survival rates from laryngeal cancer, he said. [Laser surgery results are] always better than what I expected-the patients are happier. The bottom line is maybe I need to change my expectation for this procedure. -Gady Har-El, MD He said that treatment methods that delay surgery might be too risky, with too many physicians saying, Let's try to preserve function, let's try to preserve the larynx, and if it doesn't work, we'll do the surgery. Guess what? Dr. Har-El said. Along this way, along the treatment protocol, we are losing people. Laryngologists are often pointed in different directions, he said, noting two seemingly diametrically opposed statements from two prominent physicians, both made in 1994. I believe that most patients with carcinoma of the larynx are best treated surgically, he quoted Jonas T. Johnson, MD, as saying. He quoted Patrick Gullane, MD, as saying that he tends to treat all patients with T1 to T3 laryngeal cancers with primary radiation. It takes quite a bit of practice to learn how to do this properly. If you have a very large specimen, with an endoscope, it's not easy to deal with. -Stanley Shapshay, MD

Factors to Consider
Dr. Har-El said that voice preservation cannot be given the same weight for all types of laryngeal procedures. Voice expectations should be stratified according to the degree and the extent of the surgery

that you do, he said. Although he cannot always give patients predictable voice results with a CO2 laser, the results are usually relatively positive. It's always better than what I expected-the patients are happier, he said. The bottom line is maybe I need to change my expectation for this procedure. In these cases, he said, a request for secondary augmentation to improve voice quality is the exception, not the rule. With so many treatment options available, quality of life factors have to be considered, including airway protection, speech, swallowing, and many others. When quality of voice is factored in, doctors should keep in mind an important point: Most patients are not professional voice users. He also emphasized that some tumors respond better to radiation than others-T2a responds better than T2b-and that must be factored in. He also said that the length of the treatment package has an impact on survival rates that is independent of the stage of the disease.

Developments in Laser Procedures

Stanley Shapshay, MD, Professor of Otolaryngology at Albany Medical College in New York, said that the use of the laser has come a long way since Jako's landmark 1972 paper, Laser Surgery of the Vocal Cords on Dogs. That was followed by the development of clinical applications for benign and malignant indications of using the laser by M. Stuart Strong, MD, and Charles W. Vaughan, MD. Images from their work show clean cuts in their procedures, demonstrating a principle that Dr. Shapshay said still holds true today. It's really the surgeon who uses the tool who really makes the difference, he said. Nonetheless, their novel approach was met with biting resistance. Comments were made to Drs. Strong and Vaughan that, 'You're committing malpractice by using a laser. This is not surgery. We use a scalpel to do surgery.' That criticism probably stalled further development, Dr. Shapshay said. I think it set back progress a number of years, he said. Dr. Strong was afraid of pursuing this further, I believe, because of the comments and criticism that he received of doing endoscopic resection of cancer. In the end, history has shown that, Dr. Shapshay said, We really need to keep an open mind. The numbers presented by Dr. Shapshay demonstrate the success of the laser. A study published as early as 1984 showed that in 103 cases of lesions treated with an excisional bxCO2 laser, most had good results three years later. In 35 cases of squamous cell carcinoma, 31 showed no evidence of disease, an 89% success rate. All 12 cases of verrucous carcinoma showed no evidence of disease, and all three cases of spindle-cell carcinoma were without disease. Advancements have been made in refinement of the instruments and the lasers, Dr. Shapshay noted. There are new laryngoscopes for both glottic and supraglottic exposure, including triangular design and a bivalve for wide exposure. Refinements in the use of the CO2 laser-delivery have included smaller spot size and suprapulse delivery. And there are new microlaryngeal instruments for transoral laser microsurgery, with suction, cautery, and vascular clips, as well as angled telescopes. In another milestone, Walter Thumfart, MD, and Hans Eckel, MD, introduced their four forms of

endolaryngeal laser partial laryngectomies: the vocal cord mucosal type, for tumors in situ; the cordectomy for the anterior one-third of the cord, for T1a lesions; the extended cordectomy, from the anterior commissure to the cartilage to the cricothyroid membrane, for T1b lesions; and laryngeal exenteration, for T2 lesions. When prognosticating voice outcome subsequent to early glottic cancer treatment, patients' particular anatomy and how much lamina propria they may have underlying the tumor can be as important as the shape and location of the cancer. -Stephen M. Zeitels, MD

Evidence of Effectiveness
Dr. Shapshay presented a litany of evidence vouching for the effectiveness of endoscopic treatment (see sidebar). Certainly, it's proven to be oncologically safe for selected patients with early and advanced glottic and supraglottic cancer, he said. But he cautioned that patients should be chosen carefully for transoral laser microsurgery. Surgeons need good pathology support, and there's no substitute for experience. It takes quite a bit of practice to learn how to do this properly, he said. If you have a very large specimen, with an endoscope, it's not easy to deal with. Steffen Maune, MD, PhD, Professor and Head of the Department of Otorhinolaryngology-Head and Neck Surgery at the Municipal Hospital in Cologne, Germany, emphasized the importance of diagnostic techniques before surgery is performed, including endoscopy and ultrasound of the neck. He also drew attention to the use of the stepwise resection, removing a lesion through a series of cuts rather than one sweeping move. This allows microscopic control of the incision, better control over the deeper parts of the procedure, and identification of the relationship of the tumor to the cartilage, and means better observation of resection margins. In addition, he highlighted the need for carefully handling of the tumor to avoid the spread of metastases. We are able to decide how much distance we want to have, he said. You need either R-0 resection, which is very important for the prognosis, or optimal postoperative function, which is part of the advantage of the laser. It lets you peel down to get to an R-0 situation correlated with optimal quality of life. Steven M. Zeitels, MD, the Eugene B. Casey Professor of Laryngeal Surgery at Harvard Medical School and the Director of the Center for Laryngeal Surgery and Voice Rehabilitation at Massachusetts General Hospital in Boston, said there were exciting prospects for restoring voice through phonosurgical procedures. In a case he presented, a woman who was nearly without a voice due to a T2b glottic cancer in which the dominant side of the cancer extended out to the thyroid lamina. We decided to split the tumor, cut one side out conventionally, and treat the other side with an angiolytic laser to see if we could recover any epithelial superficial lamina propria, he said. On the side in which the cancer was resected to the thyroid lamina, the vocal fold was reconstructed with a fat transplantation as well as a transcervical medialization laryngoplasty and anterior commissure thyroid lamina subluxation. Five years later, she had voice that wasn't perfect, but functioned quite well. Her glottal valve was aerodynamically competent. This is a pretty reasonable voice for where she started, he said. She functions completely as a management professor by utilizing just one vocal fold to oscillate.

He then discussed the case of a prominent Israeli comedian who had voice problems. He's a little hoarse, but when you see what was inside of him, it's quite remarkable, Dr. Zeitels said. This was circumferential glottic and subglottic exophytic papillary cancer that had progressed all the way into the trachea. But although the tumor was widespread within the larynx, it was not growing deep into the paraglottic space. By using the 532-nm pulsed-KTP laser, the cancer has been controlled, and his voice is now better than it had been in a decade. When prognosticating voice outcome subsequent to early glottic cancer treatment, patients' particular anatomy and how much lamina propria they may have underlying the tumor can be as important as the shape and location of the cancer, Dr. Zeitels said. He also discussed the exciting prospects of the use of biomaterials to help restore voice, pointing out how researchers have shown how a piece of biomaterial can restore pliability even to a vocal cord made stiff by inserting a plastic angiocatheter submucosally through the vocal fold of a cadaver. The catheter-stiffened vocal fold simulates the vibratory characteristics of a successfully treated cancer. It's stiff as a board, so that we have to get something underneath the membrane to restore pliability, Dr. Zeitels said. Is this perfect? No, he said. Can you re-establish vocal-fold vibration? Yes-even with a piece of plastic still there. This is kind of exciting, because you can imagine this is the future of cancer management, he said. This, ultimately, for many patients will turn into an office-based injection procedure.

Studies Indicate Procedure's Efficacy

A study on laser treatment presented by Wolfgang Steiner, MD, in 2005 showed that of 333 patients with T1a tumors, 89.3% had their lesions controlled after five years, and 97.6% of those had their larynx preserved. Out of 212 patients with T2 tumors, 84% with the T2a type had their lesions controlled after five years, as did 74% of the T2b patients. The larynx had been preserved in 95% of the T2a patients and in 85% of the T2b patients. In 2006, a study by Giorgio Peretti, MD, et al. showed that endoscopic resection for early glottic cancer patients yielded good results. The 13 patients with tumors in situ had a local control rate of 92% after five years, and 75 patients with T1 lesions had a rate of 90%. The larynx had been preserved in 94.4% of patients. The 67 patients with T2 type glottic cancer had a local control rate of 82% after five years, and the larynx was preserved in 94% of the patients. Dr. Shapshay said that with his own patients, from 1982 to 2006, he achieved good results with endoscopic treatment. Out of 287 patients with severe dysplasia and cancer in situ, the control rate was 85%, with a follow-up after at least 30 months. For 185 patients with T1a lesions, the control rate was 91%. For 14 patients with T1b and T2 lesions, the rate was 82%. For 31 patients with recurrent T1 lesions who received post-op radiation therapy, it was 79%, and for 27 patients with either verrucous and spindle-cell carcinoma, it was 90%. In a 2007 study by Michael Hinni, MD, et al., 117 patients were treated with transoral laser miscrosurgery for lesions from T2 to T4, both glottic and supraglottic, with 45 also receiving radiation

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