The document discusses endoscopic and open neck conservative surgery options for laryngeal cancer preservation. It summarizes the epidemiology, diagnosis, and treatment of laryngeal tumors including transoral laser surgery for glottic and supraglottic tumors. Oncologic and functional results of endoscopic cordectomies, partial laryngectomies, and open neck conservative surgeries like vertical partial laryngectomy and supracricoid partial laryngectomy are presented based on level III evidence studies. The document emphasizes that endoscopic surgery and open neck conservative surgeries can achieve high laryngeal preservation rates with good oncologic control and functional outcomes for early laryngeal cancers.

1. The International Federation
of Head and Neck Oncologic Societies
Current Concepts in Head and Neck Surgery and Oncology 2012
Endoscopic Surgery for
Laryngeal Function Preservation
Piero Nicolai

2. TUMORS OF THE LARYNX
EPIDEMIOLOGY
• Second most common
malignancy of the UADT
• Over 11,000 case/yr in US (2007)
with 3,660 deaths
• M:F=3.8:1
• 90% of pts are older than 40 yrs
• 85%-95% squamous cell
carcinoma
• Tobacco and alcohol are the two
most important risk factors
2012
Data from Cummings,
Otolaryngology Head and Neck
Surgery, 5th Ed.

3. TRANSORAL LASER SURGERY
DISEASE TREATMENT
CONTROL MORBIDITY
OPEN NECK CONSERVATIVE SURGERY
2012

4. DIAGNOSTIC WORK-UP
TARGETS
OP
KERATOSIS
• Histology
• Superficial spreading
SCC
• Deep/Submucosal invasion
• Multifocality O
• Synchronous lesions
2012

5. DIAGNOSTIC WORK-UP
PREOPERATIVE
• Flexible panendoscopy
• Videolaryngostroboscopy
• Autofluorescence
• Narrow Band Imaging
• Imaging
2012

6. DIAGNOSTIC WORK-UP
PREOPERATIVE
• Flexible panendoscopy
MACROSCOPIC APPEARANCE
2012
LARYNGEAL MOBILITY

7. DIAGNOSTIC WORK-UP
PREOPERATIVE
• Narrow Band Imaging (NBI)
Type I: Type II:
well-demarcated brownish undemarcated area with
area with thick dark spots scattered irregular and
winding vessels
Type III:
2012
presence of an afferent hypertrophic vessel
branching out in small vascular loops in the context
Piazza et al.2009
of the lesion

8. DIAGNOSTIC WORK-UP
PREOPERATIVE
Imaging (CT, MRI) check list:
PS T
• Laryngeal framework
• Paraglottic and preepiglottic PES
space
• Submucosal spread
C
• Soft tissues A
• N status
C
2012

9. DIAGNOSTIC WORK-UP
PREOPERATIVE
PARAGLOTTIC SPACE
INVOLVEMENT and
ARYTENOID SCLEROSIS
2012 PREEPIGLOTTIC SPACE LARYNGEAL FRAMEWORK
INVOLVEMENT INFILTRATION

10. DIAGNOSTIC WORK-UP
INTRAOPERATIVE
30°
70°
• Microlaryngoscopy with 0° and
angled telescopes
0°
• Narrow Band Imaging with HDTV
• Saline infusion into Reinke s space
2012

11. TRANSORAL LASER SURGERY FOR
GLOTTIC TUMORS
INDICATIONS
Tis-T1 and selected T2-T3N0 SCC
Inadequate exposure
Salvage surgery after RT in rT1 and
rT2 lesions Crico-arytenoid joint and/or posterior
Poorly radiosensitive histologies paraglottic space involvement
Posterior commissure involvement
Laryngeal framework infiltration
Transcommissural vertical extension
(?)
CONTRAINDICATIONS
2012

12. TRANSORAL LASER SURGERY
ENDOSCOPIC CORDECTOMIES
Type I Type II Type III
2012
Remacle et al. 2000

13. TRANSORAL LASER SURGERY
ENDOSCOPIC CORDECTOMIES
2012
TYPE I and TYPE II

14. TRANSORAL LASER SURGERY
ENDOSCOPIC CORDECTOMIES
Type IV Type Va Type Vb Type Vc Type Vd
Type VI
2012
Remacle et al. 2000, 2007

15. TRANSORAL LASER SURGERY
PIECEMEAL TECHNIQUE
2012

16. TRANSORAL LASER SURGERY
ENDOSCOPIC CORDECTOMIES
PIECEMEAL TECHNIQUE
2012
ENDOSCOPIC PARTIAL
LARYNGECTOMY

17. TRANSORAL LASER SURGERY FOR
SUPRAGLOTTIC TUMORS
INDICATIONS
• T1-T2 and selected T3 (with limited • Inadequate exposure
involvement of the PES) • Crico-arytenoid joint and/or
• Salvage surgery after RT for rT1-rT2 paraglottic space involvement
• Poorly radiosensitive histologies
• Massive PES involvement
• Laryngeal framework
infiltration
• Extension to the glottis
CONTRAINDICATIONS
2012

18. TRANSORAL LASER SURGERY
ENDOSCOPIC SUPRAGLOTTIC LARYNGECTOMIES
2012
Remacle et al. 2009

19. TRANSORAL LASER SURGERY
ENDOSCOPIC SUPRAGLOTTIC LARYNGECTOMIES
2012
Remacle et al. 2009

20. TRANSORAL LASER SURGERY
ENDOSCOPIC SUPRAGLOTTIC LARYNGECTOMIES
2012

21. TRANSORAL LASER SURGERY
ONCOLOGIC RESULTS (Level III)
Local control
Author Site N° of pts.
(5 yrs)
Eckel, 1998 Supraglottic 46 (T1-T2) 91
12 (T1) 100
Ambrosch,1998 Supraglottic
36 (T2) 89
Rudert, 2000 Supraglottic 56 (T1-T4) 77
Davis, 2004 Supraglottic 46 (T2) 97
84 (T2a)
Steiner, 2005 Glottic 212 (T2a-b)
74 (T2b)
Motta, 2005 Glottic 236 T2 61
Mortuaire, 2006 Glottic 104 T1a-b 84
Puxeddu, 2006 Glottic 96 T1a-b 98.3
Peretti, 2010 Glottic 109 T2 98
2012
Peretti, 2010 Supraglottic 80 (Tis-T3) 97
Peretti, 2010 Glottic 404 (312 T1a; 92 T1b) 99

22. ENDOSCOPIC CORDECTOMIES
FUNCTIONAL RESULTS
Patients treated by Type I and II cordectomies present vocal outcomes comparable to those of a control
(normal) population
Peretti et al, Ann Otol Rhinol Laryngol, 2003
Patients affected by T1a glottic tumors without involvement of the anterior commissure present
comparable vocal outcomes when treated by RT or endoscopic surgery
Wedman et al, Eur Arch ORL,
2002
A metanalysis of the VHI related data in the literature about patients treated by endoscopic resections or
RT for T1 glottic tumors doesn t show any statistical significant difference among the two groups
Cohen et al, Ann Otol Rhinol Laryngol, 2006
A comparison between functional outcomes in patients treated by endoscopic partial laryngectomies for
T2-T3 glottic tumors and those treated by supracricoid partial laryngectomies for similar lesions shows
comparable vocal outcomes but reduced postoperative morbidity and better swallowing in the
endoscopic group
Peretti et al, COSM, 2007
2012

23. ENDOSCOPIC CORDECTOMIES
FUNCTIONAL RESULTS
In a recent review Spielmann et al. examined 21 papers evaluating quality of life
and functional outcomes in the management of early glottic carcinoma comparing
radiotherapy and transoral laser surgery. No randomized controlled trials were
identified.
For vocal outcomes the majority of studies found no significant difference between
RT and laser surgery.
Nine studies reported QOL outcomes; seven showed no difference in overall scores.
No study that assessed swallow function was identified.
The evidence base to date demonstrates comparable voice and quality of life
outcomes. There is a need for consensus on which measures of vocal quality and
2012
life satisfaction to be used in research trials to allow comparison between studies.
Spielmann et al, Clinical Otolaryngology, 2010

24. 2012

25. OPEN-NECK CONSERVATIVE SURGERY
INDICATIONS
• T2 and selected T3/T4a glottic/supraglottic
lesions
• Unfavorable endoscopic laryngeal exposure
• Salvage surgery after RT or endoscopic
failure for rT1-rT2
• Good pulmonary performance
CONTRAINDICATIONS
• Invasion of the crico-arytenoid joint and/or posterior
parglottic space
• Involvement of the posterior commissure
• T4a for invasion through the cartilage or invasion
beyond the larynx
• Advanced T category after RT, CHT-RT, or
2012
conservative surgery failure
• Advanced age (?)

26. OPEN-NECK CONSERVATIVE SURGERY
Vertical partial laryngectomy
2012

27. OPEN-NECK CONSERVATIVE SURGERY
Horizontal supraglottic laryngectomy
2012

28. OPEN-NECK CONSERVATIVE SURGERY
Supracricoid partial laryngectomy
2012
CHEP

29. OPEN-NECK CONSERVATIVE SURGERY
Supracricoid partial laryngectomy
CHP
2012

30. OPEN-NECK CONSERVATIVE SURGERY
ONCOLOGIC RESULTS (Level III)
Local control Organ
Author Surgery T category
(5 yrs) preservation
T1 (25) 98
Mohr, 1983 VPL -
T2 (27) 99
T1 (146) 89
Laccourreye, 1991 VPL -
T2 (102) 74
T1 (2)
T2 (41)
Chevalier, 1994 CHP 97 -
T3 (14)
T4 (4)
Laccourreye, 1997 CHEP T1b-T2 (62) 98 100
Spriano, 1997 HSL T1-T2 (54) 96 -
T2 (22)
Chevalier, 1997 CHEP 97 95.5
T3 (90)
T1 (9) 100
Isaacs, 1998 HSL T2 (24) 78 95.0
T3 (9) 72
Bron, 2000 CHEP T1- T4 (59) 84 87.0
Laccourreye, 2000 VPL T2 (85) 69 78.0
T1 (62) 100
Giovanni, 2001 VPL -
T2 (65) 94
Dufour, 2004 CHEP T3 (37) 93 89.8
CHP T3 (81) 93 89.8
2012 T1 (16)
Bron, 2005 HSL T2 (46) 92 89.6
T3 (13)
Nakayama, 2008 CHEP T1-T4 (47) 100 70

31. OPEN-NECK CONSERVATIVE SURGERY
FUNCTIONAL RESULTS
Vertical Partial Laryngectomy
The functional outcome after standard vertical hemilaryngectomy is some degree of
permanent hoarseness. Hirano el al. compared the vocal function after a variety of
reconstruction and noted that poor outcome was ofter associated with free mucosal
grafts.
Chronic dysphagia is not associated with standard vertical partial laryngectomy, with or
without resection of the vocal process, and 92% of patients resumed a normal
postoperative diet in one month. From Cummings, Otorhinolaryngology
Head and Neck Surgery, 5th Ed.
Horizontal Supraglottic Laryngectomy
Prades reported a rate of permanent aspiration between 1.5% and 21%, and between
0% and 50% of non decannulated patients. Prades, Eur Arch Otorhinolaryngol, 2005
Sevilla et al. reported a 9% incidence of total laryngectomy due to aspiration
pneumonia, and 15% of permanent tracheostomy due to laryngeal stenosis or edema.
2012
Sevilla et al, Eur Arch Otorhinolaryngol 2008

32. OPEN-NECK CONSERVATIVE SURGERY
FUNCTIONAL RESULTS
Supracricoid Partial Laryngectomies
Aspiration pneumonia is the most common complication after SCPL. In a series
of 457 patients, normal swallowing was observed in 58.9%. Aspiration correlated
with increased age, CHP, not repositioning of the piriform sinus, and removal of
one arytenoid. However, management of aspiration required a permanent
gastrostomy in only 0.6% of patients and completion total laryngectomy in
Benito et al, Head Neck, 2011
1.5%.
Laccourreye reported tracheal tube removal in 97.2% of patients, and 52.1%
achieved normal swallowing in the first postoperative month. Aspiration
pneumonia developed in 21.7% and by the end of the first year the incidence of
completion total laryngectomy and permanent gastrostomy was 1.4%.
2012
Laccourreye et al, Laryngoscope 1998

33. OPEN-NECK CONSERVATIVE SURGERY
FUNCTIONAL RESULTS
Supracricoid partial laryngectomies
Functional
Functional
laryngectomy
Author Surgery Patients Duration NGT laryngectomy
for aspiration
for aspiration
(%)
Guerriet et al CHEP 58 9-50 1 1,7
Traissac and
CHEP 97 10-33 1 1
Verhulst
Piquet and
CHEP 104 21-45 0 0
Chevalier
Laccourreye
CHEP 67 11-40 0 0
et al
CHEP 46 10-90 0 0
Piquet
CHP 72 ? 3 4,2
Labayle and
CHP 101 ? 3 3
Dahan
2012
Maurice et al CHP 43 17-120 1 2,3
Data from Cummings, Otolaryngology Head and Neck Surgery, 5th Ed."

34. Highest-Level Evidence for Treatment Options for Early
Laryngeal Cancer (Level III)
Reference N° of patients Methodology Group Outcome
Stoeckli et Final laryngeal
Retrospective
preservation: initial
al. 101 nonrandomized, glottic RT vs laser
surgery better than
2003 tumors
RT
Gourin et
T1
Retrospective
Survival: no
al. 89 nonrandomized, all RT vs surgery
difference
2009 laryngeal sites
Retrospective
Jones et al. 364 nonrandomized, glottic
RT vs surgery (laser or open Local control: no
2010 and supraglottic
resection) difference
Marandas Initial local control
Retrospective
surgery 88%, RT 79%
et al. 66 nonrandomized, T2 with RT vs open surgery
(no statistical
2002 impaired motility
analysis)
Initial local control
Stoeckli et and
Retrospective
al. 39
nonrandomized
RT vs laser final laryngeal
2003
T2
preservation: initial
surgery better than RT
Gourin et Retrospective
al. 98 nonrandomized, all RT vs surgery Survival: no difference
2009 laryngeal sites
2012
Jones et al. 124
Retrospective RT vs surgery (laser or open Local control: no
2010 nonrandomized resection) difference

35. CONSERVATIVE SURGERY
CONCLUSIONS
TLS in early-intermediate glottic and supraglottic tumors allows diagnosis
and treatment in the same surgical procedure, and is associated with
oncological outcomes comparable to those obtained with other surgical and
not-surgical therapeutic approaches.
Open-neck conservative surgery offers the patients with intermediate-
advanced glottic and supraglottic tumors an excellent local control of the
disease counterbalanced by a long hospitalization time and recovery of
swallowing function.
Waiting for Level II studies comparing different conservative surgical
strategies or conservative surgical treatment vs a non-surgical organ
preservation protocol, selection of treatment should be customized based
2012
on tumor and patient factors, with an accurate discussion on quality of life
issues and specific needs of the patient.