Giorgio Peretti

Proposal for revision of the European Laryngological Society classification of endoscopic cordectomies.

A classification of laryngeal endoscopic cordectomies, which included eight different types, was first proposed by the European Laryngological Society in 2000. The purpose of this proposal of classification was an attempt to reach better consensus amongst clinicians and agree on uniformity in reporting the extent and depth of resection of cordectomy procedures, to allow relevant comparisons within the literature when presenting/publishing the results of surgery, and to recommend the use of guidelines to allow for reproducibility amongst practicing laryngologists. A total of 24 article citations of this classification have been found through the science citation index, as well as 3 book chapters on larynx cancer surgery, confirming its acceptance. However, on reflection, and with the passage of time, lesions originating at the anterior commissure have not been clearly described and, for that reason, a new endoscopic cordectomy (type VI) for cancers of the anterior commissure, which have extended or not to one or both of the vocal folds, without infiltration of the thyroid cartilage is now being proposed by the European Laryngological Society Committee on Nomenclature to revise and complete the initially reported classification.

Transoral CO2 laser treatment for Tis–T3 glottic cancer: The University of Brescia experience on 595 patients

Transoral CO2 laser surgery has been accepted as a valuable therapeutic option for glottic cancer.

Endoscopic CO2 Laser Excision for Tis, T1, and T2 Glottic Carcinomas: Cure Rate and Prognostic Factors:

We present the results of a retrospective study based on a cohort of 140 patients who underwent endoscopic CO2 laser excision for previously untreated early glottic cancer (21 Tis, 96 T1, and 23 T2). This study used univariate analysis to review the impact on disease-free survival of 15 factors related to the host, the tumor, and the treatment. Recurrent cancer developed in 28 patients with an average interval to recurrence of 37.5 months. Retreatment consisted of different procedures, including laser excision, partial or total laryngectomy, and/or radiotherapy. The larynx was definitively preserved in 96% of patients. By the end of the study, 14 patients had died, but only 2 of them had died of the disease. Five-year overall survival and determinate survival were 93% and 98%, respectively. Ultimate local control at 5 years with CO2 laser excision alone was 95% for Tis, 87% for T1, and 91% for T2 lesions. Only involvement of the anterior third of the vocal cord (P = 0.02), involvement of the false vocal cord (P = 0.02), and infiltration of the vocalis muscle (P = 0.004) showed a significant negative impact on disease-free survival.

Narrow band imaging and high definition television in the assessment of laryngeal cancer: a prospective study on 279 patients

Narrow band imaging (NBI) is an optical technique in which a filtered light reveals superficial carcinomas in view of their neoangiogenic pattern. The accuracy of NBI is implemented by combining it with a high definition television (HDTV) camera. The aim of this study was to prospectively evaluate the diagnostic gain of NBI and HDTV in the assessment of laryngeal squamous cell carcinoma (LSCC). Between April 2007 and December 2008, we analyzed by NBI with or without HDTV 279 patients divided in two groups: Group A included 96 patients affected by LSCC and Group B included 183 subjects under follow-up after treatment for the same disease. Overall, 50 of 279 patients (18%) showed “suspicious” NBI findings histologically confirmed as neoplastic. The sensitivity, specificity, accuracy, positive and negative predictive rates of flexible NBI, HDTV with white light, and HDTV with NBI in both groups confirmed the value of these two technologies. In the pre- and intraoperative settings, NBI with or without HDTV provided better definition of tumor staging and surgical margins. NBI has also a role in the postoperative setting, due to its ability in early detection of persistences, recurrences, and metachronous tumors.

Analysis of recurrences in 322 TIS, T1, or T2 glottic carcinomas treated by carbon dioxide laser

An endoscopic approach to early glottic carcinoma is considered a sound treatment for both previously untreated lesions and selected recurrent lesions. Between January 1988 and December 2000, we treated 322 patients by CO2 laser at a single institution; 37 had Tis, 191 T1a, 55 T1b, and 39 T2 lesions (mean follow-up, 77 months; range, 6 to 180 months). Kaplan-Meier curves showed a 5-year overall survival rate of 88%, a determinate survival rate of 99%, a disease-free survival rate of 81%, a rate of ultimate local control with laser alone of 91%, and a laryngeal preservation rate of 97%. Univariate and multivariate analysis showed that the only factor that statistically affected endoscopic control was lateral extension of the tumor with involvement of the bottom of the ventricle (hazard risk ratio, 4.0; 95% confidence interval, 1.71 to 9.35). The 58 recurrences were classified according to their location compared with the site of the primary tumor as follows: 14 in the same area (group A), 27 in adjacent subsites with superficial spreading or multifocal distribution (group B), and 17 in adjacent sites by submucosal diffusion to the visceral spaces, cartilaginous framework, or extralaryngeal tissues (group C). For each group, we analyzed the rate of patients who underwent salvage by endoscopic or open neck procedures and the rate of laryngeal preservation. Recurrences in groups A and B were endoscopically treated in 86% and 74% of cases, respectively. By contrast, in group C no patient was endoscopically cured, and there was a low laryngeal preservation rate (47%). The pathways of spread in recurrent carcinoma are therefore the single most important factor in predicting its endoscopic curability.

Vocal outcome after endoscopic cordectomies for Tis and T1 glottic carcinomas

A cohort of 101 patients with previously untreated glottic cancer (15 Tis, 66 T1a, and 20 T1b) who underwent endoscopic CO2 laser excision between January 1995 and December 1997 was prospectively analyzed. The depth and extension of the excision were graded according to the European Laryngological Society Classification including 5 types of cordectomy. All patients were subsequently examined every 2 months for a period ranging from 30 to 66 months (mean, 48 months). The rates of 5-year overall survival, disease-free survival, ultimate local control with laser alone, and laryngeal preservation were 85%, 87%, 93%, and 95%, respectively. Sixty-nine patients underwent, at least 1 year after surgery, videolaryngostroboscopy combined with perceptual and objective evaluation of the voice, and spirometry. Acoustic parameters were compared with those obtained in a matched control group by Kruskal-Wallis test. No statistically significant difference was found (p > .05) between patients submitted to subepithelial (type I) and subligamental (type II) cordectomies and controls.

Comparison of functional outcomes after endoscopic versus open-neck supraglottic laryngectomies.

Objectives: Endoscopic supraglottic laryngectomy (ESL) by carbon dioxide laser for selected T1-T3 supraglottic squamous cell carcinomas is a sound procedure with oncological results comparable to those obtained by open-neck supraglottic laryngectomy (ONSL). The aim of this study was to retrospectively evaluate functional outcomes after ESL in comparison with ONSL. Methods: We performed perceptual voice evaluation by GRBAS (grade, roughness, breathiness, asthenicity, strain), subjective analysis by Voice Handicap Index, objective analysis with the Multidimensional Voice Program, swallowing evaluation with the M. D. Anderson Dysphagia Inventory, video nasal endoscopic examination of swallowing, videofluoroscopy, and analysis of hospitalization time, need for and duration of feeding tube and tracheotomy, and complication and aspiration pneumonia rates in a group of 14 patients treated with ESL. These results were compared to those obtained in a historical group of 14 patients matched for T category who were treated with ONSL at the same institution. Statistical analysis was performed with the Mann-Whitney U and Pearson χ2 tests. Results: Comparison of comprehensive voice analysis, M. D. Anderson Dysphagia Inventory, and complication and aspiration rates showed no statistically significant differences between the Two groups. However, significant differences were found for video nasal endoscopic examination of swallowing (p = .03), videofluoroscopy (p = .03), hospitalization (p = .0001), feeding tube duration (p = .0001), and tracheotomy duration (p = .0001). Conclusions: Endoscopic supraglottic laryngectomy had a significantly lower functional impact on swallowing than ONSL, even though it was not subjectively perceived by patients, and was associated with less morbidity and a shorter hospitalization time.

Oncological results of endoscopic resections of Tis and T1 glottic carcinomas by carbon dioxide laser.

A cohort of 88 patients with glottic cancer (13 Tis, 75 T1) who underwent endoscopic CO2 laser excision between January 1995 and June 1997 was prospectively studied. The mean follow-up was 43 months (range, 30 to 60 months). The depth and extent of the excision (graded according to the European Laryngological Society Classification, which includes 5 types of resection) were based on the results of a preoperative and intraoperative diagnostic test battery. Five patients died of other diseases, and none of glottic cancer. Of the 12 patients who developed a local recurrence, 5 underwent a second endoscopic procedure, 5 a total laryngectomy, and 1 a supracricoid laryngectomy, and 1 was treated with radiotherapy. The 5-year local control rate with endoscopic surgery alone, according to the Kaplan-Meier method, was 91%. None of the variables (8 related to the tumor and 2 to the treatment) tested in a univariate analysis by the log-rank test was found to have a significant impact on disease-free survival rates. The present study confirmed that endoscopic partial cordectomy for Tis and T1 glottic cancers can be regarded as a valid alternative to radiotherapy in terms of oncological results.

The distribution of lymph node metastases in supraglottic squamous cell carcinoma: Therapeutic implications

The treatment of the neck in cancer of the upper aerodigestive tract is still a matter of controversy, even though nowadays there is a trend in the literature toward elective surgery in the N0 neck when the probability of occult lymph node metastasis is greater than 20%. In the elective setup, every effort is made for preservation of uninvolved nonlymphatic structures in positive neck. The aim of this study is to analyze in a large cohort of patients treated for supraglottic carcinoma the prevalence of lymph node metastases and their distribution through various neck levels to redefine our policy of neck treatment.

Narrow band imaging and high definition television in evaluation of oral and oropharyngeal squamous cell cancer: a prospective study.

Narrow band imaging (NBI) is an optical technique in which filtered light enhances superficial neoplasms based on their neoangiogenic pattern. The accuracy of NBI can be augmented by combining it with high definition television (HDTV). The aim of this study was to prospectively assess the diagnostic value of NBI in combination with HDTV in evaluation of oral (O) and oropharyngeal (OP) squamous cell carcinoma (SCC). Between April 2007 and December 2009, we analyzed 96 patients who were divided into 2 groups: Group A included 35 patients previously biopsied and diagnosed with OSCC or OPSCC and subjected to pre- and intraoperative HDTV white light (WL) and HDTV NBI endoscopy; Group B included 61 subjects already treated for OSCC or OPSCC and followed-up with HDTV WL and HDTV NBI. Fourteen of 35 (40%) patients in Group A showed adjunctive findings with NBI compared to standard WL. All of these findings were histologically confirmed. Twelve of 61 (20%) patients in Group B showed positive NBI findings, which were all confirmed by histology. The sensitivity, specificity, positive, negative predictive values, and accuracy for HDTV WL were 51%, 100%, 100%, 87%, and 68%, respectively, whilst for HDTV NBI were 96%, 100%, 100%, 93%, and 97%, respectively. Overall, 26 of 96 (27%) patients had a diagnostic advantage in applying NBI and HDTV: 6 patients received a diagnosis of recurrence and 1 of persistence after previous treatments; 5 showed a metachronous tumour; in 4 a synchronous tumour was diagnosed; 9 lesions were upstaged; in 1 patient previously diagnosed with an unknown primary by fine needle aspiration cytology on the neck, an anterior tonsillar pillar cancer was identified.