Abstract
Purpose
Early laryngeal cancer is successfully managed with transoral laser microsurgery. Previously radiated patients may experience more post-operative complications. We investigate disease-free survival and secondarily prolonged pain and chondronecrosis.
Materials and methods
Retrospective review of 52 patients undergoing transoral laser microsurgery after previous radiation.
Results
Mean disease-free survival was 36.7 months. Overall disease-free survival was 57.6% at 3-year and 48.4% at 5-year follow-up, with no significant difference between surgery within as opposed to after 60 months of radiation or within as opposed to after 12 months of radiation. Thirteen patients, all with surgery within 60 months of radiation, experienced prolonged pain. Twelve experienced chondronecrosis, all within 12 months of surgery.
Conclusion
Transoral laser microsurgery for early laryngeal cancer is an adequate therapeutic option in patients with history of radiation with comparable disease-free survival to other reports. Patients undergoing transoral laser microsurgery within 60 months of radiation treatment are more likely to experience prolonged pain.
1
Introduction
According to the American Cancer Society Cancer Facts and Figures, 12,740 new cases of laryngeal cancer were diagnosed in the United States in 2011 . Treatment options for early-stage supraglottic and glottic cancer are radiation, open partial laryngectomy, or transoral laser microsurgery (TLM), as per the 2012 National Comprehensive Cancer Network (NCCN) guidelines. Radiation is often preferred as initial treatment with the objective of better preserving voice and swallowing function. Barthel and Esclamado report local control rates following radiation of 87.5% and 75% for T1 and T2 glottic cancers, respectively. Recent studies comparing TLM with radiation therapy have found equivalent local control rates and overall survival . Advocates for the use of TLM as initial treatment argue that this will allow radiation to remain an option for treatment of cancer persistence or recurrence .
In patients with cancer persistence or recurrence after radiation to the head and neck, total laryngectomy was considered the gold standard for salvage surgery for many years. While it still is the best treatment option for advanced laryngeal cancer, early cases can be salvaged by TLM . There is abundant literature on TLM as primary treatment for laryngeal cancer, with less information about TLM after radiation. A few reports are available and confirm favorable outcomes with TLM, however few data are available for incidence of prolonged pain and chondronecrosis . Quer et al. reported favorable outcomes with transoral laser surgery on 24 patients, with only 1 patient needing tracheostomy and no cases of chondronecrosis, for example.
Radiation is known to permanently affect the capacity of tissue to heal. Studies of total laryngectomy specimens that were exposed to previous radiation showed a decrease in muscle fibers as compared to specimens from patients without a history of radiation . It may thus be inaccurate to counsel patients undergoing this procedure after prior radiation by extrapolating data from reports on patients with primary TLM. This investigation aims to examine the outcomes on the specific subgroup of patients who have been previously irradiated and subsequently underwent TLM for laryngeal squamous cell cancer. We suspect that patients with a history of radiation who undergo TLM are more likely to suffer from prolonged pain and chondronecrosis. These data will provide clinicians with the information necessary to adequately counsel their patients on post-operative expectations in terms of both survival and functional outcome.
2
Materials and methods
University of Miami Institutional Review Board approved the retrospective chart review of all patients who underwent partial laryngectomy between January 1998 and November 2011, based on billing records (IRB# 20110937). Patients included in this study are those with a history of radiation to the head and neck who subsequently underwent TLM for persistent, recurrence, or a new primary laryngeal squamous cell carcinoma. Patients who had an open partial or total laryngectomy prior to TLM were excluded.
Clinical and demographic data were collected, including patients’ gender, age, location of initial cancer and second cancer, initial treatment with radiation or with concurrent chemoradiation, and the stage of initial and second cancer. Smoking status was recorded as current, former, or non-smoker, as explicitly stated in the medical record. A former smoker was defined as a patient who quit within the 12 months prior to TLM. A non-smoker was a patient who indicated they had never used tobacco products. The number of months between completion of radiation and date of TLM was calculated. We used this time interval to define groups for comparing outcomes. Two time points were considered. Twelve months after radiation was used as a surrogate cutoff for persistent versus recurrent disease. Sixty months after radiation was used as a surrogate cutoff for second primary cancer. These groups were compared both for survival as well as incidence of prolonged pain and chondronecrosis. Details regarding the original cancer were reviewed when available. Patients who recurred after TLM were followed up and salvage total laryngectomies were recorded. Functional outcomes measured were tracheostomy dependence at most recent follow-up, feeding tube dependence at most recent follow-up, and prolonged pain, as defined as pain reported at 1-month post-operative appointment. In addition, chondronecrosis was recorded, as defined as poor wound healing noted on fiberoptic evaluation and requiring antibiotics. Time interval between TLM and the development of chondronecrosis was calculated.
Descriptive statistics are reported as mean (range) for quantitative variables and as a percentage for qualitative variables. Kaplan–Meier method was used for survival analysis. Survival analysis for the overall cohort was performed. Survival analysis was also performed comparing disease-free survival between two groups, which were defined based on the time point of 12 months between radiation and TLM (group 1, < 12 months; group 2, ≥ 12 months). The same survival analysis was performed using a different cutoff time point (group 3, < 60 months; group 4, ≥ 60 months). The difference in disease-free survival between groups was analyzed using a log-rank test. The incidence of chondronecrosis and prolonged pain were compared between groups using the same cutoff time points of 12 and 60 months between radiation and TLM, and Fisher’s Exact Tests were used to assess the relationship between these variables. All statistical significance in the current study was based on a significant level of 0.05.
2
Materials and methods
University of Miami Institutional Review Board approved the retrospective chart review of all patients who underwent partial laryngectomy between January 1998 and November 2011, based on billing records (IRB# 20110937). Patients included in this study are those with a history of radiation to the head and neck who subsequently underwent TLM for persistent, recurrence, or a new primary laryngeal squamous cell carcinoma. Patients who had an open partial or total laryngectomy prior to TLM were excluded.
Clinical and demographic data were collected, including patients’ gender, age, location of initial cancer and second cancer, initial treatment with radiation or with concurrent chemoradiation, and the stage of initial and second cancer. Smoking status was recorded as current, former, or non-smoker, as explicitly stated in the medical record. A former smoker was defined as a patient who quit within the 12 months prior to TLM. A non-smoker was a patient who indicated they had never used tobacco products. The number of months between completion of radiation and date of TLM was calculated. We used this time interval to define groups for comparing outcomes. Two time points were considered. Twelve months after radiation was used as a surrogate cutoff for persistent versus recurrent disease. Sixty months after radiation was used as a surrogate cutoff for second primary cancer. These groups were compared both for survival as well as incidence of prolonged pain and chondronecrosis. Details regarding the original cancer were reviewed when available. Patients who recurred after TLM were followed up and salvage total laryngectomies were recorded. Functional outcomes measured were tracheostomy dependence at most recent follow-up, feeding tube dependence at most recent follow-up, and prolonged pain, as defined as pain reported at 1-month post-operative appointment. In addition, chondronecrosis was recorded, as defined as poor wound healing noted on fiberoptic evaluation and requiring antibiotics. Time interval between TLM and the development of chondronecrosis was calculated.
Descriptive statistics are reported as mean (range) for quantitative variables and as a percentage for qualitative variables. Kaplan–Meier method was used for survival analysis. Survival analysis for the overall cohort was performed. Survival analysis was also performed comparing disease-free survival between two groups, which were defined based on the time point of 12 months between radiation and TLM (group 1, < 12 months; group 2, ≥ 12 months). The same survival analysis was performed using a different cutoff time point (group 3, < 60 months; group 4, ≥ 60 months). The difference in disease-free survival between groups was analyzed using a log-rank test. The incidence of chondronecrosis and prolonged pain were compared between groups using the same cutoff time points of 12 and 60 months between radiation and TLM, and Fisher’s Exact Tests were used to assess the relationship between these variables. All statistical significance in the current study was based on a significant level of 0.05.
3
Results
Fifty-two patients met the inclusion criteria of the 384 patient charts identified and reviewed. Gender distribution was 44 men (85%) and 8 women (15%). Mean age was 66 years (ranging from 45–86). Thirteen patients (25%) were categorized as current smokers, 31 as former smokers (60%), and 7 as non-smokers (13%). Smoking information was not explicitly stated in the medical record for 1 patient. Sixteen patients (31%) had TLM within 12 months after radiation, 37 patients (71%) had TLM within 60 months after radiation, and 15 patients (29%) after 60 months after radiation. Patient characteristics are summarized in Table 1 .
| Characteristic | Number of patients (%) |
|---|---|
| Gender | |
| Men | 44 (85) |
| Women | 8 (15) |
| Smoking | |
| Current | 13 (25) |
| Former | 31 (60) |
| Non-smoker | 7 (13) |
| Initial treatment | |
| XRT | 40 (77) |
| XRT and Chemo | 12 (23) |
| Initial cancer (treated with XRT) | |
| Supraglottis | 7 (13) |
| Glottis | 36 (69) |
| Subglottis | 0 |
| Oropharynx | 6 (12) |
| Nasopharynx | 1 (2) |
| Second cancer (treated with TLM) | |
| Supraglottis | 15 (29) |
| Glottis | 37 (71) |
| Second cancer stage | |
| T1 | 21 (40) |
| T2 | 20 (38) |
| T3 | 2 (4) |
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