2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Zeitels and Burns

Declaration of Conflicting Interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors have not received commercial financial sup- port but have received laser instrumentation from Laserscope (now American Medical Systems). Dr Zeitels has an equity inter- est in Endocraft LLC. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by the following nonprofit foundations: National Philanthropic Trust, ‘V’ Foundation, Eugene B. Casey Foundation, and the Voice Health Institute. References 1. Fraenkel B. First healing of a laryngeal cancer taken out through the natural passages. Archiv fur Klinische Chirurgie . 1886;12:283-286. 2. Lynch RC. Intrinsic carcinoma of the larynx, with a second report of the cases operated on by suspension and dissection. Transactions of the American Laryngological Association . 1920;40:119-126. 3. New GB, Dorton HE. Suspension laryngoscopy in the treat- ment of malignant disease of the hypopharynx and larynx. Mayo Clin Proc . 1941;16:411-416. 4. DeSanto LW. Selection of treatment for in situ and early inva- sive carcinoma of the glottis. Can J Otolaryngol . 1974;3:552- 556. 5. Jako GJ, Kleinsasser O. Endolaryngeal micro-diagnosis and microsurgery. Reprint from the Annual Meeting of the American Medical Association, 1966. 6. Jako GJ. Laser surgery of the vocal cords. Laryngoscope . 1972;82:2204-2215. 7. Strong MS, Jako GJ. Laser surgery of the larynx: early clini- cal experience with continuous CO 2 laser. Ann Otol Rhinol Laryngol . 1972;81:791-798. 8. Vaughan CW. Transoral laryngeal surgery using the CO 2 laser. Laboratory experiments and clinical experience. Laryngoscope . 1978;88:1399-1420. 9. Vaughan CW, Strong MS, Jako GJ. Laryngeal carci- noma: transoral treatment using the CO 2 laser. Am J Surg . 1978;136:490-493. 10. Hirano M, Hirade Y, Kawasaki H. Vocal function following carbon dioxide laser surgery for glottic carcinoma. Ann Otol Rhinol Laryngol . 1985;94:232-235. 11. Zeitels SM, Vaughan CW. A submucosal vocal fold infusion needle. Otolaryngol Head Neck Surg . 1991;105:478-479. 12. Zeitels SM. Premalignant epithelium and microinvasive can- cer of the vocal fold: the evolution of phonomicrosurgical management. Laryngoscope . 1995;105(suppl 67):1-51. 13. Zeitels SM. Phonomicrosurgical treatment of early glottic cancer and carcinoma in situ. Am J Surg . 1996;172:704- 709. 14. Zeitels SM. Vocal fold atypia/dysplasia and carcinoma. In: Atlas of Phonomicrosurgery and Other Endolaryngeal Procedures for Benign and Malignant Disease . San Diego, CA: Singular; 2001:177-218.

oncologic advantage over other endoscopic surgical tech- niques since the cure rate in all of them is generally very high. The data herein demonstrate that T1 tumors (regardless of bilateral disease) are substantially easier to cure than T2 lesions, which is consistent with other modalities. It is not surprising that tumors with significant subglottic and/or supraglottic extension were more difficult to control. The data herein for treating T2 disease are comparable to results achieved with reported CO 2 transoral laser microsurgery 39 and radiotherapy. 40 Although higher single-modality cure rates are reported with hyperfractionated radiotherapy for T2 disease, successful functional salvage is substantially more likely with initial angiolytic KTP laser treatment. Salvaging radiotherapy failures for T2 disease is associated with a 92% incidence of total laryngectomy, 41 but total lar- yngectomy was necessary in only 43% (3/7) after failed angiolytic KTP laser treatment. Moreover, KTP laser pho- toablation treatment of early glottic cancer after failed radiotherapy could be done in 80% of those with limited recurrence. 42 However, clinicians must remain vigilant about the need for neck treatment with substantial supra- glottic extension. A key unique metric for success in this series is that radiotherapy was preserved as a future oncologic option in 91% (107/117) of patients with early glottic cancer. Given the oncologic efficacy demonstrated by the data herein, along with the previously reported excellent voice results 37 and technical advantages, 23 KTP laser photoablation should be considered by other investigators. Moreover, radiother- apy is typically a single-use cancer treatment so that endol- aryngeal management preserves key discretionary treatment options for the future, including radiotherapy alone or in combination with any type of surgery. This is an increas- ingly important asset in the management strategy of early glottic cancer since patients are predisposed to encounter- ing metachronous lesions, especially given the predilection to multifocal human papillomavirus 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. In the overwhelming majority of patients, glottic preservation was achieved and radiotherapy could be preserved for future use. Since a majority of patients are referred by an otolaryn- gologist to undergo treatment of early glottic cancer with radiotherapy, this investigation provides compelling infor- mation to reappraise this paradigm. Authors’ Note This article was presented at the 94th Annual Meeting of the American Broncho-Esophagological Association on May 14-15, 2014, and received the Broyles Maloney Award.

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