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Transoral laser microsurgery is an increasingly common treatment modality for glottic carcinoma. This study aimed to determine the effect of age, gender, stage and time on voice-related quality of life using the Voice Handicap Index-10.
Primary early glottic carcinoma patients treated with transoral laser microsurgery were included in the study. Self-reported Voice Handicap Index testing was completed pre-operatively, three months post-operatively, and yearly at follow-up appointments.
Voice Handicap Index improvement was found to be dependent on age and tumour stage, while no significant differences were found in Voice Handicap Index for gender. Voice Handicap Index score was significantly improved at 12 months and 24 months. Time versus Voice Handicap Index modelling revealed a preference for non-linear over linear regression.
Age and stage are important factors, as younger patients with more advanced tumours show greater voice improvement post-operatively. Patient's Voice Handicap Index is predicted to have 95 per cent of maximal improvement by 5.5 months post-operatively.
To modify the non-porous surface membrane of a tissue-engineered laryngeal scaffold to allow effective cell entry.
The mechanical properties, surface topography and chemistry of polyhedral oligomeric silsesquioxane poly(carbonate-urea) urethane were characterised. A laser technique introduced surface perforations. Micro computed tomography generated porosity data. Scaffolds were seeded with cells, investigated histologically and proliferation studied. Incubation and time effects were assessed.
Laser cutting perforated the polymer, connecting the substructure with the ex-scaffold environment and increasing porosity (porous, non-perforated = 87.9 per cent; porous, laser-perforated at intensities 3 = 96.4 per cent and 6 = 89.5 per cent). Cellular studies confirmed improved cell viability. Histology showed cells adherent to the scaffold surface and cells within perforations, and indicated that cells migrated into the scaffolds. After 15 days of incubation, scanning electron microscopy revealed an 11 per cent reduction in pore diameter, correlating with a decrease in Young's modulus.
Introducing surface perforations presents a viable method of improving polyhedral oligomeric silsesquioxane poly(carbonate-urea) urethane as a tissue-engineered scaffold.
The choices made by patients offered treatment for early laryngeal cancer with radiotherapy or transoral laser resection were reviewed.
A prospective review was conducted of all patients diagnosed and treated for early laryngeal carcinoma from December 2002 to September 2009 at the Leeds Teaching Hospitals NHS Trust. A total of 209 patients with tumour stage T1 or T2 laryngeal cancer were treated; each new patient suitable for radiotherapy or transoral laser resection was seen jointly by the clinical (radiation) oncologist and head and neck surgeon, and offered the choice of treatment.
Of the patients, 47.4 per cent were given a choice between radiotherapy and transoral laser resection; 51.2 per cent were advised to have radiotherapy, and there were no records for the remaining 1.4 per cent. From those given the choice, 59.6 per cent chose transoral laser resection (p < 0.02 (t-test)) and 35.4 per cent chose radiotherapy.
When given the choice, a statistically significant majority of patients choose transoral laser resection rather than radiotherapy.
This study aimed to evaluate the oncological and voice outcomes of transoral laser microsurgery for tumour stage T1b stage glottic cancer patients.
A prospective cohort study in a tertiary care head and neck cancer centre included tumour–node–metastasis stage T1bN0M0 glottic cancer patients scheduled to undergo transoral laser microsurgery from January 2002 until June 2014. Kaplan–Meier five-year analyses of local control, overall survival, disease-specific survival and laryngeal preservation were performed. Voice Handicap Index-10 scores and maximum phonation times were also recorded.
Twenty-one participants with a mean age of 66.8 years were enrolled. The mean follow up was 56.5 months. Kaplan–Meier 5-year survival analysis illustrated a local control rate of 82 per cent, overall survival of 88 per cent, disease-specific survival of 100 per cent, and laryngeal preservation of 100 per cent. The pre-operative Voice Handicap Index-10 score was 19.1 ± 9.47 (mean ± standard deviation (SD)) and the post-operative scores were 13.5 ± 9.29 at three months, 10.44 ± 9.70 at one year and 5.83 ± 4.91 at two years. The pre-operative maximum phonation time was 16.23 ± 5.46 seconds (mean ± SD) and the post-operative values were 14.44 ± 6.73 seconds at three months, 15.27 ± 5.71 seconds at one year and 14.33 ± 6.44 seconds at two years.
Transoral laser microsurgery yields relatively high rates of oncological control and acceptable voice outcomes, and thus shows utility as a primary treatment modality for T1b glottic cancer.
The study aimed to evaluate the effect of a patient-to-patient communication model on dysphagia in laryngeal cancer patients after total laryngectomy.
Sixty-five patients who had undergone total laryngectomy were randomly divided into three groups: a routine communication group, a patient communication group (that received the patient-to-patient communication model) and a physician communication group. Questionnaires were used to compare quality of life and swallowing problems among all patient groups.
The main factors causing dysphagia in total laryngectomy patients were related to fear and mental health. The patient communication group had improved visual analogue scale scores at one week after starting to eat. Quality of life in swallowing disorders questionnaire scores were significantly higher in the patient communication and physician communication groups than in the routine communication group. In addition, swallowing problems were much more severe in patients educated to high school level and above than in others.
The patient-to-patient communication model can be used to resolve swallowing problems caused by psychological factors in total laryngectomy patients.
This study assessed the relationship between vascular endothelial growth factor expression and the laryngeal cancer prognosis.
Systematic computerised searches of PubMed were performed up to 31 January 2015. Prognostic endpoints were overall survival and disease-free survival. The pooled hazard ratios for overall survival and disease-free survival were also calculated.
Seven studies containing 975 patients were included. The pooled hazard ratio was 1.703 (95 per cent confidence interval, 1.373 to 2.112; z score = 4.85, p = 0.000) for overall survival and was 1.918 (95 per cent confidence interval, 1.410 to 2.609; z score = 4.15, p = 0.000) for disease-free survival. No significant publication bias was found. A sensitivity analysis showed that the results were robust. Power analyses also showed there was enough power to detect the calculated hazard ratios.
The study found that vascular endothelial growth factor overexpression predicted a worse prognosis for laryngeal cancer patients. This supports a strategy of targeted therapy by blocking the vascular endothelial growth factor receptor.
Head and neck cancer emergency presentations are uncommon but persistent. However, there is little published literature on this aspect of cancer and patient demographics. This study aimed to assess the incidence, patient profile, tumour site and stage of emergency cancer presentations in our region.
Retrospective review of regional cancer database over a five-year period.
Emergency presentations accounted for 7 per cent of all cases. There was no difference in patient age and risk factors between the emergency and non-emergency presentations. The emergency presentation group showed a greater proportion of female patients compared to the non-emergency presentation group (30 vs 15 per cent). In all emergency presentations, the cancer was at advanced stages. Oropharyngeal cancer was the commonest emergency presentation of cancer, but the third commonest in the non-emergency group.
Emergency presentations are increasing annually. Female patients and oropharyngeal cancer showed greater representation compared to male patients and laryngeal cancer.
Although type 2 respiratory failure is a plausible late presentation for laryngeal tumours, very little published literature is available to support this theory.
This paper describes the unusual presentation of a subglottic tumour with uncompensated type 2 respiratory failure.
The patient was initially managed with biphasic positive airway pressure as a bridging measure while awaiting intensive care treatment and to provide sufficient time to arrange a surgical tracheostomy.
This case highlights the importance of clinical suspicion towards subglottic tumours in patients presenting with type 2 respiratory failure. The positive outcome indicates that biphasic positive airway pressure is a potential bridging therapy for upper airway obstruction and a safe and stable treatment option for patients in respiratory distress.
This study aimed to assess the influence of supra- and subglottic extensions and vocal fold mobility on outcome in a large monocentric cohort of 148 patients treated for tumour–node–metastasis stage T2N0 glottic carcinomas.
In all, 107 glottic carcinoma patients had normal vocal fold mobility (T2aN0), and 41 had impaired vocal fold mobility (T2bN0). Treatment decisions were made by a multidisciplinary team.
Vocal fold mobility was associated with overall survival, disease-free survival, local control, larynx preservation and laryngectomy-free survival. For patients with T2a lesions, local control, laryngectomy-free survival and disease-free survival improved after surgery but overall survival did not. For patients with T2b lesions, local control, laryngectomy-free survival, disease-free survival and overall survival were all higher after surgery than after radiotherapy.
This study highlights for the first time the importance of vocal fold mobility in treatment outcomes and is the first to assess its influence on survival. Updated tumour–node–metastasis classifications should consider the distinction between T2a and T2b lesions.
This paper reports the outcome of using acellular dermal matrix to repair a cervical skin defect in a patient with an advanced laryngeal carcinoma that had invaded the skin.
A 55-year-old man underwent surgical repair of severe atypical hyperplasia and of a squamous cell carcinoma at 17 and 9 months, respectively, prior to undergoing the current procedure. Five months prior to the current procedure, his left cervical skin broke down and the lesion gradually enlarged. A pathological diagnosis of squamous cell carcinoma was made. The cervical skin defect was repaired with a tailored acellular dermal matrix patch. The cervical wound completely healed without developing infection or a pharyngeal fistula, and the patient exhibited no dysphagia three years after surgery.
Cervical skin defects can be successfully repaired with acellular dermal matrix.
To review the literature on enhanced recovery programmes in head and neck surgery.
A systematic review was performed in May 2013.
Thirteen articles discussing enhanced recovery after laryngectomy, neck dissection, major ablative surgery and microvascular reconstruction were identified. Articles on general pre-operative preparation and post-operative care were also reviewed.
Considerable evidence is available supporting enhanced recovery in head and neck surgery that could be of benefit to patients and which surgeons should be aware of.
Laryngeal dysplasia is an important pre-malignant lesion. In 2010, a consensus statement by ENT surgeons and pathologists was published outlining the management and follow up of patients with laryngeal dysplasia.
After reviewing these guidelines, we noted the need for a flowchart for laryngologists to improve efficiency in managing dysplasia and encourage adherence to evidence-based protocols.
A diagram has been produced to aid other ENT units around the country.
This study aimed to report our current practice of transoral laser microsurgery for early glottic cancer against the standards outlined by the ENT UK Head and Neck Group and assess the oncological outcome.
A retrospective review of case notes of patients diagnosed with early glottic cancer (tumour stages Tis, T1 and T2) who underwent transoral laser microsurgery as a primary curative treatment. The minimum follow-up period was two years.
Thirty-one patients had transoral laser microsurgery for early glottic cancer during the study period. Eighty-four per cent of cases were discussed by a multidisciplinary team prior to transoral laser microsurgery. Complete circumferential excision was achieved in 77 per cent of cases. Sixty-five per cent of specimens were subjected to histological analysis; they complied with standard pathology reporting for margins. Within 12 months of transoral laser microsurgery, there were 10 residual cases and 2 recurrences. Kaplan–Meier survival analysis gave disease-free survival rates of 96.8 per cent at 18 months and 93.5 per cent at 24 months. The laryngectomy-free survival rate was 96.8 per cent at two years.
The findings of this audit are encouraging and have highlighted areas for further discussions, recommendations, training and education.
Granulation tissue after transoral laser microsurgery can make it difficult to distinguish between normal healing and tumour recurrence.
Materials and methods:
We carried out a retrospective analysis of 316 consecutive glottic carcinomas (Tis–T3). Presence of granulation tissue at one and six months was correlated with demographic and clinical data, tumour and surgical characteristics, and tumour relapse.
Granulation tissue appeared in 53.8 per cent of patients at month 1, resolving spontaneously in 41.8 per cent. Revision surgery was performed in 60.1 per cent and was effective in 41.1 per cent. At month 6, 14.9 per cent of patients presented with granulation tissue. In 74.5 per cent the tissue was surgically removed and was positive for malignancy in 62.9 per cent. Tumour relapse presented in 29.4 per cent with granulation tissue at month 1 and in 61.7 per cent at month 6 (p = 0.000). Granulation tissue at month 1 correlated with thyroid cartilage exposure and continued smoking. At month 6, granulation tissue correlated with thyroid cartilage exposure, the affected surgical margins and diabetes.
Granulation tissue after transoral laser microsurgery is frequent. When it persists at six months, revision surgery is formally recommended.
To determine whether a threshold apparent diffusion coefficient value may help to differentiate laryngeal carcinomas from benign lesions.
Fifty-three patients with laryngeal masses were recruited; four of them were excluded because of susceptibility artefacts. In the remaining 49 patients, the pathological results showed 32 laryngeal carcinomas and 17 benign lesions. The diagnostic value of diffusion-weighted magnetic resonance imaging for the identification of malignant lesions was determined. In addition, the agreement between diffusion-weighted magnetic resonance imaging and histopathology was assessed. Moreover, the sensitivity, specificity, and negative and positive predictive values of the apparent diffusion coefficient in detecting benign and malignant lesions were analysed. An apparent diffusion coefficient histogram was also produced.
An apparent diffusion coefficient value of 1.1 × 10−3 mm2/second produced the best result when used as the cut-off point to differentiate malignant from benign masses.
An apparent diffusion coefficient threshold of 1.1 × 10−3 mm2/second is optimal for distinguishing laryngeal carcinomas from benign lesions. Apparent diffusion coefficient values were lower for patients with laryngeal carcinomas than for those with benign lesions.
Complementary and alternative medicine usage, though rising, remains largely devoid of a sound scientific basis; however, there is increasing evidence to support its use in cancer therapy.
To present the case of a patient with laryngeal carcinoma who made a full recovery following mistletoe therapy, despite failing to respond to chemoradiotherapy and salvage laryngectomy.
Case report with relevant literature review.
The patient developed extensive, unresectable stomal recurrence, and it was deemed appropriate to supply palliative care only. Following treatment with mistletoe extract injections after palliative radiotherapy, he recovered fully and was eventually discharged from care.
The benefit of mistletoe in laryngeal cancer treatment requires further investigation, and might be considered in selected patients, as an adjunct or when other conventional therapies have failed.
Liposarcomas of the larynx and its sub-sites are rare. Within this group of tumours, well-differentiated liposarcomas of the epiglottis have been only sporadically reported. In view of its infrequent presentation, difficulty still exists over the diagnosis of this pathological entity, together with uncertainty over its exact accepted management.
We present the case of a well-differentiated liposarcoma of the epiglottis, and we review the associated English-language literature.
The reported patient underwent multiple attempts at surgical treatment prior to establishment of a firm diagnosis. In light of the diagnosis and other mitigating factors, a conservative approach was adopted.
A high index of clinical suspicion and detailed histological analysis are required when encountering a recurrent soft tissue lesion of the larynx. In the presented case, a multidisciplinary approach and conservative management plan were adopted, based on a holistic management approach and a review of the published literature.
Laryngeal cancer patients who continue to smoke after treatment are at an elevated risk of mortality and morbidity. This study aimed to identify factors associated with continued tobacco use following treatment in patients with laryngeal cancer.
A smoking behaviour questionnaire, a self-report measure, was sent to 112 patients who were diagnosed with laryngeal cancer during 2006–2011 at the Brighton and Sussex University Hospitals, Brighton, UK. Patient demographics, tumour and treatment-related variables, comorbidity and socio-economic status were obtained from the medical records.
Eighty-one per cent of patients responded to the survey; 22 per cent of these reported continued tobacco use after treatment. Treatment modality was found to be a predictor of post-therapeutic smoking (odds ratio: 4.9, p = 0.01); patients who received less invasive therapy (transoral laser microsurgery) were more likely to smoke after treatment.
The findings of this preliminary study suggest that treatment modality influences smoking behaviour in patients with laryngeal cancer, which may have important implications for the design of anti-smoking interventions.
To compare the image quality provided by rigid laryngoscopes versus flexible distal-chip laryngoscopes when documenting the same laryngeal pathology.
This paper reports a prospective single-blind study. Ten early stage glottic cancer cases were selected. Photographs of the pathologies were taken using both rigid and flexible distal-chip laryngoscopes (a total of 20 photographs). Nineteen clinicians were asked to review the laryngoscopic photographs; the clinicians were provided with a worksheet, which included questions regarding the clinical description, photograph quality and overall satisfaction with the images obtained. Clinicians' responses to the worksheet questions were then analysed.
The overall accuracy rate for lesion sidedness, anatomical sub-site involvement, anterior commissure involvement and tumour staging were 94.7 per cent, 46.6 per cent, 53.7 per cent and 47.1 per cent respectively. There were no statistically significant differences in terms of the accuracy rates, photograph quality or overall satisfaction with the photographs obtained by either modality.
There were no statistically significant differences demonstrated in overall clinical accuracy or perceived image quality between the use of the rigid or flexible endoscopes when interpreting images of early glottic cancer.
Asian patients with laryngeal cancer have been reported to have a high prevalence of thyroid involvement. This study aimed to investigate the prevalence of thyroid invasion in Iranian patients with laryngeal cancer.
Hospital records for all patients with a definite diagnosis of laryngeal cancer between 1996 and 2009 (351 patients) were reviewed, and the prevalence of thyroid invasion was established based on the pathology report at the time of surgery.
Thyroid invasion was found in 16 patients (4.55 percent), and was limited to one thyroid lobe in two-thirds of cases. All instances of thyroid invasion occurred in patients with stage III (81.25 percent) or IV (18.75 percent) cancer. No case of metastasis was reported. The glottic region was identified as the tumour origin in most cases of thyroid invasion (56.25 percent).
Most cases of thyroid invasion by laryngeal cancer occurred in cancer stage III, at grades G1 and G2, among male patients, and arose from tumours of the glottic region.