Evidence-based medicine integrates the best available data in decision making, with the goal of minimizing physicians' and patients' subjectivity. In 2006, the American Society of Clinical Oncology edited clinical practice guidelines for the use of larynx preservation strategies. The objective of this review was to evaluate the current levels of evidence for glottic squamous cell carcinoma. Current guidelines for early stage glottic cancer are based on low-level evidence. Conservation surgery (open or transoral) and radiation therapy are all valid options for T1 and selected T2 lesions. For advanced lesions, surgery and combined chemotherapy and radiation are options. High-level evidence favors combined chemotherapy and radiation therapy or altered fractionation radiation therapy as nonsurgical strategies for organ preservation, compared with radiation therapy alone. The optimal combination of chemotherapy, targeted therapy, and radiation therapy remains to be demonstrated, however, and for high-volume tumors, total laryngectomy may still be warranted.

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Evidence-based review of treatment options for patients with glottic cancer

A retrospective analysis of the medical records and operative files of 124 patients who consecutively underwent supracricoid partial laryngectomy with cricohyoidopexy (SCPL-CHP) was undertaken. The objective of this study was to analyze the postoperative course and functional results of SCPL-CHP. The mean duration of follow-up was 7 years (range 1 to 20 years). The postoperative mortality was 1.6%. The average times until tracheostomy and nasogastric feeding tube removal were 8 and 22 days, respectively. All patients but 1 were decannulated. The rate of pneumonia from aspiration was 11.5%. Completion total laryngectomy and permanent gastrostomy were required in 2.5% and 2.5% of patients, respectively. Overall normal swallowing without permanent gastrostomy and respiration without tracheostomy were achieved by the first postoperative year in 91% and 99.1% of patients, respectively. Univariate analysis of the potential correlation between various variables and the duration of the tracheostomy and nasogastric feeding tube, the incidence and causes of mortality, the incidence and type of the various complications, the recovery of swallowing, and the length of hospitalization is presented. The report also discusses the management and follow-up care.

Functional Outcome and Prognosis Factors after Supracricoid Partial Laryngectomy with Cricohyoidopexy

Background
This study was undertaken to analyze the functional results, complications, local control rates, and survival in patients undergoing conservation surgery for squamous cell carcinoma (SCC) of the larynx as a salvage procedure for recurrent tumors after previous radiotherapy.

Methods
Twenty-one patients underwent frontolateral laryngectomy for radiation failure, T1 and T2 glottic SCC, at the Cancer Institute Hospital, Tokyo, from 1976 to 1991. All patients were men between the ages of 42 and 83 years. The disease-free interval ranged from 1 to 87 months (median, 26 months). The stage at initial treatment was T1 in 17 patients and T2 in four patients. Local recurrence developed in three patients.

Results
The rate of local control was influenced by a surgical margin of less than 1 mm (p < 0.05). Overall voice preservation was achieved in 86% of the patients. The 5-year and 10-year survival rates following frontolateral laryngectomy were 86% and 70%, respectively. Maximum phonation time after surgery ranged from 4 to 18 seconds (median, 8.1 seconds).

Conclusions
These results indicate that in carefully selected cases, frontolateral laryngectomy may be used for treating radiation failure stage I or II vocal cord carcinomas with good success. Careful follow-up may be necessary in patients with a close surgical margin. © 1997 John Wiley & Sons, Inc. Head Neck19: 116–120, 1997.

Partial laryngectomy in the treatment of radiation-failure of early glottic carcinoma.

A consecutive series of 28 patients treated by conservation surgery of the larynx for radiation-failure, recurrent rT1 and T2 (postradiotherapy staging) glottic squamous cell carcinoma treated at Memorial Sloan-Kettering Cancer Center from 1966 to 1983 is reviewed. The majority of patients were men with the age ranging from 46 to 76 years. The disease-free interval ranged from 0 to 113 months (median, 8.5 months). The stage at presentation was rT1 in 25 patients and rT2 in 3 patients. Surgery consisted of cordectomy (7 patients), hemilaryngectomy (18), and extended hemilaryngectomy (3). There was no operative mortality. Local recurrence developed in 8 patients (28.5%), cervical metastasis in 2, and distant metastasis in 1. Only 3 patients were salvaged by further treatment. The rate of local control was influenced by positive surgical margins. Overall, voice preservation was achieved in 75% of patients. The ultimate local control was 82.1% during a follow-up period that ranged from 1.3 to 16.7 years (median, 6.3 years). The actuarial survival at 5 and 10 years was 73% and 71% following conservation surgery of the larynx.

Conservation surgery for radiation-failure carcinoma of the glottic larynx

To evaluate whether age over 70 years represents a prognostic factor in head and neck cancer, we reviewed all cases observed between 1981 and 1984. Four hundred and thirty-eight (438) patients were considered in relation to three age groups (less than or equal to 59, 60-69, and greater than or equal to 70 years, defined as non-elderly, mid-elderly and elderly respectively). The main parameters analyzed included histological diagnosis (no difference emerged among the three age groups); anatomical site (hypopharyngeal carcinoma was most frequent in non-elderly patients); TNM stage (an higher incidence of early stages was seen in the elderly); performance status (better in the non-elderly); previous illnesses (life-style related diseases were more frequent in the non-elderly); contraindications to surgery (more frequent in the elderly); surgical treatment ('en bloc' resections were more often employed in the non-elderly); post-operative complications and local control (no difference between the three groups); multiple primary malignancies (head and neck, oesophagus and lung were more frequent in non-elderly patients) and survival (no difference). Although age affects several features of head and neck cancer patients, it does not appear from the present study to be an independent prognostic factor for local control and survival. With regard to survival, stage appeared to be the most important prognostic factor.

Head and neck cancer and ageing: a retrospective study in 438 patients.

The postoperative course was evaluated for 458 consecutive patients, all over the age of 56 years, who had undergone laryngeal conservation surgery in the last 10 years. One hundred seventy-one patients aged 66 and over made up the "elderly" group and 287 patients, aged between 56 and 65 years formed the control group. It was confirmed that cordectomy and frontolateral laryngectomy are feasible even in elderly patients. Bronchopneumonia is the most frequent and serious complication after supraglottic laryngectomy. Therefore this operation should be performed in the elderly patient only after a thorough evaluation of cardiac and respiratory function. Prophylactic neck dissection should not be done for N0 necks and the second therapeutic neck dissection in N2 cancers should be staged 6 or more weeks later. Hemilaryngopharyngectomy and subtotal reconstructive laryngectomy with cricohyoidpexis are not advisable in elderly patients.

Vittorugo Agostini

Papers

Conservation surgery for cancer of the larynx in the elderly.