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Organ preservation protocols utilizing induction chemotherapy as a selection agent have played a critical role in the treatment of advanced laryngeal squamous cell carcinoma (LSCC). The selection of patients who will have a good response to chemoradiation allows for organ preservation in a significant group of patients and minimizes the rate of surgical salvage. While there remains debate regarding its utility when compared to surgery or other organ preservation regimens, the data does suggest an important role for induction chemotherapy in LSCC. In addition, there are continued opportunities to identify pretreatment biomarkers for induction chemotherapy, whether genetic, epigenetic or cellular, that could predict response to treatment and select patients to therapy (whether organ preservation or surgery). As our understanding of the biology of larynx cancer advances, induction paradigms have utility for the development and adoption of novel agents and therapeutics. The background of induction chemotherapy as a selection agent and future directions of this approach are discussed., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

A look at the past, present and future.

Hypopharynx cancer has the worst prognosis of all head and neck squamous cell cancers. Since the 1990s, a treatment shift has appeared from a total laryngectomy towards organ preservation therapies. Large randomized trials evaluating treatment strategies for hypopharynx cancer, however, remain scarce, and frequently this malignancy is evaluated together with larynx cancer. Therefore, our aim was to determine trends in incidence, treatment and survival of hypopharynx cancer. We performed a population-based cohort study including all patients diagnosed with T1-T4 hypopharynx cancer between 1991 and 2010 in the Netherlands. Patients were recorded by the national cancer registry database and verified by a national pathology database. 2999 patients were identified. The incidence increased significantly with 4.1% per year until 1997 and decreased non-significantly afterwards. For women, the incidence increased with 1.7% per year during the entire study period. Total laryngectomy as primary treatment significantly decreased, whereas radiotherapy and chemoradiation increased. The 5-year overall survival significantly increased from 28% in 1991-2000 to 34% in 2001-2010. Overall survival for T3 was equal for total laryngectomy and (chemo)radiotherapy, but for T4-patients the survival was significantly better after primary total laryngectomy (± adjuvant radiotherapy). This large population-based study demonstrates a shift in treatment preference towards organ preservation therapies. The 5-year overall survival increased significantly in the second decade. The assumed equivalence of organ preservation and laryngectomy may require reconsideration for T4 disease.

One-lung ventilation is challenging in patients with difficult airway who require lung surgery. The choice of airway technique remains limited in patients with permanent tracheostomy after total laryngectomy. Conventional airway management techniques and available airway equipment have limited the options for securing airway in such patients, and dedicated airway equipment is not available for the management of such patients. Here, using endobronchial blocker through adult silicon hyperflex tracheostomy tube with an adjustable flange, we report a successful airway management for 1-lung ventilation in a patient with total laryngectomy with permanent tracheostomy.

Objective: To identify trends in treatment and survival for patients with stage I glottic cancer and glottic carcinoma in situ (CIS)., Methods: The 18-registry SEER data were analyzed for CIS and stage I glottic cancer. Treatment variables and observed and relative survival were assessed separately for stage I and glottic CIS., Results: Among 14 025 cases of stage I glottic cancer identified from 1988 to 2012, radiation was the most common treatment for all eras. An increase in surgical treatment occurred with a decline in combination therapy. There were 3169 cases of glottic CIS, with surgery the most common initial treatment but with radiotherapy increasing across the years. Relative survival was similar for treatment type and era of diagnosis. Among the 3738 patients with glottic CIS, 5.4% went on to develop invasive glottic carcinoma of any stage, with invasive cancer more common in patients treated by surgery alone compared to radiation or surgery with radiation., Conclusions: Despite changes in treatment modalities for CIS and stage I glottic cancer, there have not been significant changes in survival for CIS, with slightly improved survival for treatment with surgery alone. Patients treated with surgery alone had an increased rate of subsequent invasive cancer., (© The Author(s) 2015.)

Purpose: The aim of this study is to evaluate the evolution of supracricoid partial laryngectomy (SCPL) in indications, surgical techniques and outcomes through last decades., Materials and Methods: A retrospective analysis of 146 patients affected by laryngeal cancer treated with SCPL was carried on. We defined: (1) group A, 100 patients treated by cold instruments between 1995 and 2004; (2) group B, 46 patients treated by harmonic scalpel between 2005 and 2010. Complications rate, and functional and oncological results were documented and a comparison between the two groups was made; histopathological analysis of surgical margins was evaluated and correlated with local incidence of recurrence., Results: Significant differences in age mean-value (p=0.02), T classification (p=0.007), and in indication for more advanced-staged patients were found in group B (p=0.001). Surgical procedure was shorter in group B (p<0.001), with shorter swallowing recovery (p=0.003). Oncological outcomes did not report any significant differences. Group B showed a higher incidence of post- operative arytenoid edema (p=0.03) associated with a lower rate of pneumonia (p=0.038). Despite a higher rate of close or positive-margins found in group B no higher incidence of local-recurrence was reported (p=0.02) compared to group A., Conclusions: We documented changing in indications and surgical technique for SCPL because of the development of modern diagnostic techniques and the introduction of low-thermal injury device allowing a more challenging tumor excision as well as with a shorter swallowing recovery in our series., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To determine if the number of total laryngectomies (TL) performed in California has changed over a 15-year period from 1996 to 2010. We also sought to investigate if the location of surgery, length of stay, use of rotational/free flaps, cost, and complications changed over this period., Study Design: Cross-sectional., Setting: California Hospital Inpatient Discharge Data sets., Subjects and Methods: All patient records enlisting International Classification of Diseases, Ninth Revision, Clinical Modification procedural codes for total/radical laryngectomy were extracted from 1996 to 2010 data sets. Patients' demographics were evaluated. Hospitals were coded as university medical centers (UMCs) vs others. Population-adjusted surgery rates, percentage of surgeries with rotational/free flap and/or percutaneous endoscopic gastrostomy (PEG), length of stay, total charges, and disposition status were then analyzed and compared between UMCs and non-UMCs., Results: A total of 4145 TLs were performed in California during 1996 to 2010. The overall number of surgeries declined from 1.3 to 0.6 per 100,000 California residents (P < .001). The number of surgeries performed in non-UMCs dropped by 70% during this period (P < .001). The median length of stay increased from 10 to 12 days, and the median total charges increased from $45,000 to $192,000 over the 15-year period. The use of rotational/free flaps more than doubled, and the use of PEG tubes increased 7-fold., Conclusion: The total number of TLs in California has declined and surgeries are currently being performed equally at UMCs and non-UMCs. The use of rotational/free flaps, costs, hospital stay length, and complications have increased over the past 15 years.

Objective: The management of advanced laryngeal cancer is evolving, with increasing use of chemoradiation as initial treatment. Recent reports confirm a decline in total laryngectomies (TLs) in the United States. A study was undertaken to evaluate national and regional trends in TLs performed over the most recent decade for which data were available and to use multivariate analysis to characterize these trends in more detail., Study Design: Population-based cohort study., Setting: Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 1998 to 2008., Subjects and Methods: All patients underwent radical or complete laryngectomy. Descriptive statistics and linear and multivariate regressions were performed on both raw case volumes and nationally extrapolated figures., Results: In this nationally representative sample, 8288 TL cases met inclusion criteria between 1998 and 2008. The TL case volumes decreased by 27.3 per year (P = .005) and showed increasing trends in high-volume centers. The number of hospitals performing TLs decreased by 12.3 per year (P < .0005). The South and Midwest showed higher case volumes even after controlling for multiple covariates., Conclusion: Total laryngectomy cases are decreasing and concentrating into high-volume centers. This study demonstrated unexplained regional variation in case volumes. These findings may affect patients, otolaryngology residency training, surgeons, and reimbursement.

Objective: To describe time trends in total laryngectomy health services utilization across the United States, such as rates of surgery, cost, length of stay, and insurance payer, and to compare this to important milestones in recommendations for laryngeal cancer treatment., Study Design: Population-based cohort study., Setting: Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) 1997-2008: stratified sample of all US hospital discharges., Subjects and Methods: All patients with the principal procedure of complete laryngectomy. The unit of analysis was the discharge., Results: Between 1997 and 2008, the number of laryngectomies done in the United States decreased by 48%. New cases of laryngeal cancer decreased 33% during the same time. The proportion of patients older than 65 years decreased from 48% to 43%. Mortality for the procedure was 1.4% in 1997 and 1.1% in 2008. Mean length of stay over the study period increased from 13 days to 14 days. Mean hospital charges rose from $58,000 in 1997 to $109,000 in 2008, consistent with the overall rise in US health care costs. Medicare was the dominant insurer throughout. Home health was ordered in 50% of 2008 discharges but only 32% in 1997., Conclusions: The rate of total laryngectomy has dropped more than the incidence of laryngeal cancer has dropped, consistent with the trend toward nonsurgical treatment. Lower surgical volumes and/or salvage laryngectomy surgeries are hypothesized to play a role in longer length of stay, stable mortality rates despite younger patient age, and increased need for home services after discharge.

Objectives/hypothesis: The past 2 decades have witnessed an increase in the use of chemoradiation in the treatment of laryngeal cancer. We sought to characterize contemporary patterns of laryngeal cancer surgical care and the effect of volume status on surgical care and short-term outcomes., Study Design: Retrospective cross-sectional study., Methods: Using the Nationwide Inpatient Sample database, temporal trends in laryngeal cancer surgical care were evaluated in 78,478 cases performed in 1993 to 2008. Relationships between volume and mortality, complications, length of stay, and costs were evaluated in 24,856 cases performed in 2003 to 2008 using regression analysis, with adjustment for patient and provider characteristics., Results: Laryngeal cancer surgery in 2001 to 2008 was associated with increased utilization of high-volume hospitals (odds ratio [OR]=2.0, P=.039), a decrease in partial and total laryngectomy procedures (OR=0.7, P<.001), an increase in flap reconstruction (OR=1.6, P<.001), prior radiation (OR=2.2, P<.001), comorbidity (OR=1.6, P<.001), and wound complications (OR=4.0, P<.001), compared to 1993 to 2000. High-volume hospitals were significantly associated with partial laryngectomy (OR=1.8, P=.026) and flap reconstruction (OR=1.8, P=.027). High-volume surgeons were associated with partial laryngectomy (OR=1.7, P=.048), flap reconstruction (OR=1.6, P=.029), prior radiation (OR=2.2, P=.013), and comorbidity (OR=0.4, P=.008). After controlling for all other variables, a statistically significant negative correlation was observed between surgery at a high-volume hospital and length of hospitalization, and surgery by a high-volume surgeon was associated with even greater reductions in length of hospitalization as well as lower hospital-related costs., Conclusions: These data reflect changing trends in the primary management of laryngeal cancer, with meaningful differences in the type of surgical care provided by high-volume providers., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: To understand the various methods available to reconstruct total laryngopharyngectomy defects and to understand which, and to what degree, various factors influence the surgeon in choosing a particular reconstructive method., Methods: Otolaryngologists and plastic surgeons who perform head and neck reconstruction were surveyed regarding preference of laryngopharyngectomy reconstruction. Numerical and rank-order data was analyzed using T statistics and Fisher exact test., Results: Two hundred surveys were mailed and 72 physicians (36% response rate) provided data, with otolaryngologists comprising 54% of the respondents. Otolaryngologists were more likely to consider voice (P = .003) and swallowing (P = .02) outcomes compared to plastic surgeons. In contrast, plastic surgeons more often included cosmesis (P = .05) among those factors influencing their reconstructive choice. However, rank-order analysis demonstrated no statistical difference between plastic surgeons and otolaryngologists with respect to each factor., Conclusions: Our study sought to examine what motivates surgeons from several specialties to choose one reconstructive method over another for laryngopharyngeal defects. Otolaryngologists were more likely to consider voice and swallowing function in contrast to plastic surgeons, who more frequently included cosmesis as a factor. However, when physicians were asked to rank the importance of each of the eight factors from most to least important in influencing their reconstructive option, there was no statistical difference between plastic surgeons and otolaryngologists with respect to each factor. Further research is necessary to provide an evidence base for which reconstructive method offers the optimal functional restoration.

Medicinal adjuvants are often used in operative laryngology but their value is judged very differently. The scientific evidence is unsatisfactory for most of these substances. For corticosteroids it is proven that in pediatric intensive care they reduce stridor following extubation. Routine prophylactic use for intubation does not seem to be justified and methylprednisolone and dexamethasone are the preferred preparations. Fibrin adhesives are well tolerated and low in side-effects. The indications for their use should be primarily limited due to the cost factor. Their use in laryngology remains a decision on an individual case-to-case basis. Mitomycin C is used because of its antiproliferative effect on fibroblasts in order to reduce scar tissue formation. Many positive effects have been attributed to the topical application but there are large differences in dosage and exposure time.

Treatment for head and neck cancer has evolved significantly during the past 100 years. Beginning with Bilroth's total laryngectomy on New Year's Day in 1873, "radical" surgery remained the only accepted treatment for head and neck cancer when optimal local and regional control was the goal. Bigger was still better when it came to managing the primary tumor and the neck. The "commando" procedure and radical neck dissection were the hallmarks of this first generation of treatments of head-and-neck cancer. With the advent of microvascular reconstructive techniques, larger and more comprehensive resections could be performed. Despite these large resections and their "mutilating" sequelae, overall survival did not improve. Even for intermediate-stage disease in head-and-neck cancer, the 5-year survival rate did not improve >50%. Many concluded that more than the scalpel was needed for optimal local and regional control, especially for intermediate- and advanced-stage disease. Most important, the multidisciplinary teams must identify and correlate biomarkers in the tumor and host that predict for a response to therapy and for optimal functional recovery. As the pendulum swings back, a scientific approach using tissue biomarkers for the response to treatment in the setting of multidisciplinary trials must emerge as the new paradigm. In the postgenomic era, treatment decisions should be made based on functional and oncologic parameters-not just to avoid perceived morbidity.

Objective: In 1991, a randomized study was published and demonstrated that use of nonsurgical therapy (chemoradiation) provided similar survival to total laryngectomy (the gold standard) for patients with advanced-stage laryngeal cancer. The purpose of this study was to assess how treatment of advanced laryngeal cancer was influenced by such developments in non-surgical therapy., Study Design: Patterns of care study using National Cancer Database (1985-2001)., Results: The percentage of advanced-stage patients treated with chemoradiation increased from 8.3% to 20.8% while the proportion treated with radiation alone decreased from 38.9% to 23.0%. Use of chemoradiation increased at a significantly faster rate after the 1991 publication at both community cancer centers and teaching research facilities. The use of total laryngectomy decreased slightly during this period., Conclusions: The use of chemoradiation increased after the 1991 publication. It was impossible to determine from the NCDB whether additional patients who could benefit from chemo-RT were not offered or did not complete this treatment option. We recommend that treatment recommendations discussed at tumor boards be recorded in cancer registries.

The open organ preservation surgical procedures are an important part of the head and neck surgeon's armamentarium for treating laryngeal cancer. The principles of organ preservation surgery as they apply to laryngeal cancer must be thoroughly appreciated and strictly applied for oncologic and functional success. The selection of eligible patients for these procedures is an art and requires a keen clinical acumen. The vertical partial laryngectomy and supraglottic laryngectomy have defined clinical applications that are relatively well accepted. The supracricoid laryngectomy continues gaining acceptance as a means of treating more extensive glottic and transglottic lesions while maintaining physiologic speech and swallowing without the need for a permanent tracheostoma. The inability to include and use the open surgical organ preservation approaches in the organ preservation paradigm for larynx cancer severely limits the patient's treatment options. Total laryngectomy and medical organ preservation protocols may not be acceptable to the patient from a quality-of-life standpoint. Therefore, it is incumbent upon the head and neck surgeon to have a thorough understanding of all the options available for treatment in the organ preservation paradigm for laryngeal cancer. These options must be skillfully evaluated as they relate to the patient's disease process and confidently used to provide the best oncologic and functional outcome.