Transoral laser surgery for recurrent glottic cancer after radiotherapy: oncologic and functional outcomes

Primary radiotherapy (RT) has been successfully employed for treatment of early glottic cancer for the past half century. However, local recurrences still occur in 5-35% of patients. Salvage options for persistent/recurrent glottic cancer include total laryngectomy, open neck partial laryngectomies (ONPLs) and transoral laser surgery (TLS). We performed a retrospective chart review of 35 patients with glottic squamous cell carcinoma previously submitted to RT and managed by TLS at the Department of Otorhinolaryngology - Head and Neck Surgery of the University of Brescia, Italy, from 1995 to 2009. Oncologic outcomes were estimated using the Kaplan-Meier method, and separately calculated for the entire cohort of patients (n = 35) and for patients with true persistent/recurrent disease (n = 30), thus excluding the second primary tumours (n = 5). Hospitalization time and complications were obtained by chart review. Functional outcomes of a subgroup of 10 patients in terms of speech and swallowing were analyzed by the Voice Handicap Index (VHI), GRBAS scale, Multi Dimensional Voice Program (MDVP), M.D. Anderson Dysphagia Inventory (MDADI) questionnaire, videoendoscopy (VEES), and videofluoroscopy (VFS) of swallowing (both graded according to Donzelli's scale), and compared to a cohort of 10 patients matched for age, gender and pT category, treated by the same team of surgeons by TLS as a primary treatment. The types of resection used were: 18 Type III, 1 Type IV, and 16 Type V cordectomies. Postoperative staging was 16 rpT1a, 17 rpT2, and 2 rpT3. The 5-year overall survival for the entire series was 91%. Five-year disease-specific survival, local control with laser alone, and organ preservation rates were 94%, 84% and 87%, respectively. Among the variables tested by univariate analysis, for the entire cohort of patients the pT category had a statistically significant impact on local control with laser alone. Anterior transcommissural extension had a borderline statistical impact on disease-specific survival, while it was clearly significant on overall survival. The status of surgical margins and presence of recurrence after TLS statistically influenced both organ preservation and local control with laser alone. The mean values of VHI, MDADI, and MDVP did not show any statistically significant difference between irradiated and non-irradiated patients. The same was true for GRBAS, VEES, and VFS. This series confirms that TLS after RT failure can be considered a successful surgical option in selected early recurrences, with functional outcomes comparable to those observed after TLS as a primary treatment, and much better than those classically described after ONPLs.