Treatment of Advanced Carcinoma of the Larynx and Hypopharynx with Laser Followed by External Radiotherapy

Document Type: Original

Authors

1 Department of Otorhinolaryngology, Christian Medical College, Vellore, India.

2 Department of Radiotherapy, Christian Medical College, Vellore, India.

Abstract

Introduction:
Radical laryngeal surgeries for extensive laryngeal and hypopharyngeal tumors often require a permanent tracheostomy, which has an immense impact on the quality of life of patients. A minimally invasive technique such as transoral laser microresection (TLM) followed by radiotherapy can preserve the functions of the voice and swallowing. The aim of this study is to evaluate the role of laser debulking in the treatment of carcinoma of the larynx and hypopharynx, to evaluate the response of the tumor to subsequent radiotherapy, and also to assess the usefulness of laser in avoiding tracheostomy and functional preservation of the voice and swallowing. 
 
Materials and Methods:
This prospective cohort study included patients with carcinoma of the larynx and hypopharynx unwilling to have definitive surgery and those medically unfit for radical surgery. The clinical profile of patients at presentation,  tumor status following laser debulking, immediately after radiotherapy (RT), 6 weeks post RT, 3 months post RT, and at the end of study; short term complications associated with laser surgery; and usefulness of laser in avoiding tracheostomy and in functional preservation of the voice were evaluated.
 
Results:
There were 18 (90%) male patients and 2 (10%) female patients. Age ranged from 24 to 78 years with a mean age of 55. Hoarseness of voice was the most frequent presenting complaint (90%) followed by progressive dysphagia (45%), odynophagia (40%), otalgia (40%), and dyspnoea (25%). 11 (55%) patients had T3 tumors, while 6 (30%) were T2,  and 3 (15%) were T4 lesions. 65% of  patients were free of lymph node metastasis at presentation. 2 (10%) had N1 and 5 (25%) had N2  nodes. At presentation 10 (50%) patients had Stage III disease and 6 (30%) had stage IV disease. 13 patients (65%) had moderately differentiated squamous cell carcinoma. None of the risk factors and co-morbid illnesses showed any statistically significant difference among the tumor sites. Apart from the 2 (10%) patients who had residual disease, 2 (10%) patients developed a recurrent tumor in the course of their follow up. None had neck recurrence. Two patients underwent tracheostomy, before laser surgery, for compromised airway and both had recurrence of their tumor and continued to be on tracheostomy.
 
Conclusion:
Laser debulking followed by radiotherapy is a viable alternative in the management of malignancies of the larynx and hypopharynx for those who refuse radical surgery and for those patients in whom radical open surgery is impractical due to physiological reasons such as advanced age and poor pulmonary reserve. 

Keywords

Main Subjects


[1]. Gallo A, Marco de Vincentiis,  Manciocco V, Simonelli M, Fiorella ML, Shah JP. CO2 Laser Cordectomy for Early-Stage Glottic Carcinoma: A Long-Term Follow-up of 156 Cases. Laryngoscope. 2002; 112: 370- 4.

2. Ferguson JC,  Carr RT,  Chang EW,   Farrior EH .Evaluation of Endotracheal Tube Safety for CO2 Laser Resurfacing. Laryngoscope. 112: July 2002; 1239-42.

3. Doweck I, Denys D, Robbins KT. Tumor Volume Predicts Outcome for Advanced Head and Neck Cancer Treated With Targeted Chemoradiotherapy. Laryngoscope. 112:1742-9.

4. Peters LJ, Wendt CD. Tumor volume as a predictor of radio-curability: a drop in the bucket? Int J Radiat Oncol Biol Phys.1990; 19:497–8.

5. Zeitels et al. Endoscopic treatment of supraglottic and hypopharyngeal cancers. Laryngoscope. 1999;104:71-8.

6. Patrick JB. Treatment of the patient with upper airway obstruction caused by cancer of the larynx. Otolaryngology–Head and Neck Surgery. 1999; 120 (5): 737-41.

7. Steiner W, Ambrosch P, Hess CF, Kron M. Organ preservation by transoral laser microsurgery in piriform sinus carcinoma. Otolaryngology– Head and Neck Surgery. Volume 124;  Number 1, 58-67.

8. Strong MS, Jako GJ. Laser surgery of the larynx. Early clinical experience with continuous CO2 laser. Ann Otol. 1972; 81: 791–8.

9. Verma R. Asian Journal of Ear, Nose and Throat. 2003; Vol1,Number3:18-21.

10. Pearson BW, Salassa JR. Transoral Laser Microresection for Cancer of the Larynx Involving the Anterior Commissure. Laryngoscope. 113: July 2003; 1104-12.

11. Rudert H. Transoral CO2-laser surgery of early glottic cancer (CIS-T2). In: Smee R, Bridger P, eds. Amsterdam, The Netherlands: Elsevier, 1994: 389–92.

12. Steiner W: Results of curative laser microsurgery of laryngeal carcinomas. American Journal of Otolaryngology. 14(2): 116-121.

13. Steiner W. Treatment of hypopharyngeal carcinoma. HNO 1994; 42:4-13, 84-8, 104-112,         147-65.

14. Herchenhorn D, Dias FL, Ferreira CG, Araújo CM, Lima RA, Small IA, Kligerman J. Impact of previous tracheotomy as a prognostic factor in patients with locally advanced squamous cell carcinoma of the larynx submitted to concomitant chemotherapy and radiation. ORL J Otorhinolaryngol Relat Spec. 2008;70(6):381-8.

15. Mittal B, Marks JE, Ogura JH.Transglottic carcinoma. Cancer. 1984; 53:151-61.