2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

538936 research-article 2014

AOR XXX10.1177/0003489414538936Annals ofOtology,Rhinology&Laryngology Zeitels andBurns Reprinted by permission of Ann Otol Rhinol Laryngol. 2014; 123(12):840-846.

Article

Annals of Otology, Rhinology & Laryngology 2014, Vol. 123(12) 840–846 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003489414538936 aor.sagepub.com

Oncologic Efficacy of Angiolytic KTP Laser Treatment of Early Glottic Cancer

Steven M. Zeitels, MD, FACS 1 and James A. Burns, MD, FACS 1

Abstract Objective: Angiolytic laser removal of early glottic cancer with ultra-narrow margins was reported in a pilot study 5 years ago as an innovative surgical treatment strategy to better preserve vocal function. Subsequently, in a cohort of > 90 patients, enhanced voice outcomes were achieved and there was diminished need for post-treatment phonosurgical reconstruction. However, the initial pilot study examining oncologic efficacy had a limited number of patients and most did not have 3-year follow-up. Consequently, further analysis of the oncologic efficacy is valuable. Method: Retrospective review. Results: One hundred seventeen patients (T1a-71, T1b-11, T2a-10, T2b-25) underwent potassium-titanyl-phosphate (KTP) laser treatment of early glottic cancer with a minimum 3-year follow-up (average = 53 months). The “b” designation delineated bilateral disease. Disease control for T1 and T2 lesions was 96% (79/82) and 80% (28/35), respectively. All 10 recurrences were treated with radiotherapy. Fifty percent (5/10) were controlled with radiotherapy, and the other 5 died of disease. Larynx preservation and survival were achieved in 99% (81/82) with T1 disease and 89% (31/35) with T2 disease. Conclusion: This investigation provides further evidence that angiolytic KTP laser removal of early glottic cancer with ultra-narrow margins is an effective oncologic treatment strategy. Radiotherapy was preserved for future use in more than 90% of patients. Since a majority of patients are referred by an otolaryngologist to undergo treatment of early glottic cancer with radiotherapy, this investigation provides compelling information to reappraise this paradigm.

Keywords glottic cancer, vocal cord cancer, vocal fold cancer, KTP laser, voice surgery, voice preservation, phonomicrosurgery

Introduction Endoscopic treatment of early glottic cancer was reported by Fraenkel 1 in 1886 as a single-handed mirror-guided resection approach. Lynch 2 initiated a bimanual direct laryngoscopic strategy using his unique laryngoscope and suspension gallows in the early 20th century. This work was subsequently advanced by New and Dorton in the 1940s. 3 In the late 1900s, the precision of endolaryngeal glottic can- cer treatment was enhanced by magnification (surgical microscope) 4,5 and more precise hemostatic cutting (carbon dioxide laser [CO 2 ]). 6-9 By the late 20th century, high cure rates were achieved routinely by experienced surgeons. Hirano et al 10 intro- duced a layered micro-resection approach with narrow deep margins to enhance postoperative aerodynamic glottal val- vular function and thereby optimize vocal function. Zeitels et al 11-14 expanded this concept, employing ultra-narrow margins, and demonstrated that normal conversation-level voice outcomes could be achieved routinely from phonomi- crosurgical treatment of early glottic cancer. 15 This investi- gation also demonstrated that a minority (20%) of T1a

lesions invade the vocalis muscle and that approximately 50% of lesions do not progress through the superficial lam- ina propria to invade the vocal ligament. This is a key rea- son that the ultra-narrow-margin approach has been successful. For those patients in whom a substantial volume of glot- tic muscle must be resected, the paraglottic region 16 can be reconstructed to reestablish glottal competency. 17 This may be done with autologous fat, 18 a transcervical medialization laryngoplasty, 19,20 and/or an anterior-commissure thyroid lamina subluxation. 19 The glottal sound source ultimately becomes the untreated, noncancerous pliable phonatory mucosa, which can effectively be identified by means of

1 Department of Surgery, Harvard Medical School; Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital,

Boston, Massachusetts, USA Corresponding Author:

Steven M. Zeitels, MD, FACS, Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, One Bowdoin Square,

11th Floor, Boston, MA 02114, USA. Email: zeitels.steven@mgh.harvard.edu

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