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ORIGINAL ARTICLE
Year : 2015  |  Volume : 11  |  Issue : 6  |  Page : 173-178

Transoral laser microsurgery for recurrent laryngeal carcinoma after primary treatment: A systematic review and meta-analysis


1 Department of Respiratory Medicine, Yidu Central Hospital, Qingzhou, 262500, Shandong Province, China
2 Department of Respiratory Medicine, College of Nursing, Tianjin Medical University, Tianjin 300054, China
3 Department of Respiratory Medicine, Qingzhou TCM Hospital, Qingzhou 262500, Shandong Province, China

Date of Web Publication26-Oct-2015

Correspondence Address:
Yikai Niu
Department of Respiratory Medicine, Yidu Central Hospital, Qingzhou 262500, Shandong Province
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.168180

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 > Abstract 

Purpose: To evaluate the efficacy and oncologic outcomes of transoral laser microsurgery (TLM) for recurrent laryngeal carcinoma after previous treatment. Materials and Methods: A systematic search in PubMed was performed using mesh word for "laryngeal cancer," crossed with "recurrent," and "TLM." The primary endpoints, including overall survival (OS) rate, local control rate, and disease-specific survival (DSS) were summarized using RevMan software. Adverse events and complications were recorded if reported. Results: The pooled odds ratios (ORs) for main outcomes, including local control, 5-year OS, and DSS were 3.08 (95% confidential indexed [95% CI], 1.88–5.05), 2.29 (95% CI, 1.42–3.67), and 5.05 (95% CI, 2.75–9.27), respectively. The pooled OR for functional outcome, larynx preservation, was 3.82 (95% CI, 2.46–5.94), whereas the pooled risk difference of local recurrence was 45% (95% CI, 26–64%). Conclusions: It seems that TLM is an effective option for recurrent laryngeal cancer with regard to the high incidence of OS, local control, and especially organ preservation. However, more prospective studies are needed to confirm its efficiency.

Keywords: Chemo-radiotherapy, laryngeal carcinoma, local control, organ preservation, overall survival, recurrent, transoral laser microsurgery


How to cite this article:
Zhong A, Xu X, Fan H, Wang L, Niu Y. Transoral laser microsurgery for recurrent laryngeal carcinoma after primary treatment: A systematic review and meta-analysis. J Can Res Ther 2015;11, Suppl S2:173-8

How to cite this URL:
Zhong A, Xu X, Fan H, Wang L, Niu Y. Transoral laser microsurgery for recurrent laryngeal carcinoma after primary treatment: A systematic review and meta-analysis. J Can Res Ther [serial online] 2015 [cited 2019 Dec 15];11:173-8. Available from: http://www.cancerjournal.net/text.asp?2015/11/6/173/168180

#Co-first author



 > Introduction Top


Radiotherapy or chemo-radiotherapy is the primary option for early glottis cancer, with their advantage of local control rates, overall survival (OS), and voice preservation.[1],[2] However, local recurrences still occur in 5–35% of cases.[3] In this context, open partial laryngectomy procedures and repeated transoral laser microsurgery (TLM) are considered as treatment options for recurrent glottis cancer after primary radiotherapy failure. Open partial laryngectomy is proved oncologically safe but high cost, and a dramatically increased incidence of complications has been reported after open partial laryngectomy.[4]

TLM, a minimally invasive operation, has been acknowledged as an alternative treatment option for early glottis cancer patients,[5],[6] and recently it has been used for the management of locally advanced laryngeal cancer.[7],[8] Since TLM exhibited a minimal morbidity and a high laryngeal preservation rate, patients have demonstrated an overwhelming preference for this option over RT.[9] Furthermore, TLM has been advocated as a salvage option for recurrent laryngeal cancer after radiotherapy failure for its decreasing length of treatment and hospital stay, fewer side effects, and improved surveillance.[10],[11],[12],[13],[14]

Given that several studies have evaluated the efficacy, oncologic outcomes, and complications in patients undergoing TLM for recurrent laryngeal carcinoma after previous treatment, such as radiotherapy, chemotherapy, or laser operation, the purpose of this meta-analysis was to statistically consider whether TLM was an effective option for recurrent laryngeal cancer.


 > Materials and Methods Top


Data sources

The PubMed database was searched with the mesh word for laryngeal cancer, AND ("TLM" OR "electroscopic laser microsurgery"). The published years were ranged from January 2000 to the present, and the language was limited to English. The reference lists of related studies and review articles were also screened.

Study selection

Qualified references were selected carefully based on the following rules: (1) Treatment of recurrent laryngeal carcinoma with TLM; (2) data collected including OS, local control, and disease-specific survival (DSS), along with the 95% confidential indexed (95% CIs).

When included studies referred to same enrolled populations, the most recently published papers were chosen.

Quality assessment

The included studies were assessed and scored for randomization (0–2 points), double-blind (0–2 points), and follow-up (0–1) points, based on which a total score was ranged from 0 to 5, and studies are defined as "good" when the score is over 3.

Data extraction

Two reviewers independently screened full-text studies and extracted all the data. Disagreements were resolved by consensus. The following information was collected from each study:First author, year of publication, patients' data (such as number of enrolled patients, age, gender, and previous treatment), outcomes and complications. Oncologic outcomes of interest were OS, local control rate, DSS, as well as organ preservation rate. When available, recurrence clinical stage (rcTis–rcT4) was recorded.

Statistical analysis

The whole analysis was performed in Review Manager software (RevMan, Version 5.3, The Nordic Cochrane Centre, The Cochrane Collaboration, 2014, Copenhagen). The pooled odds ratios (ORs) and risk differences (RDs) were calculated, along with the generation of forest plots using the random effects. The heterogeneity between publications was assessed by the Chi-squared Q-test. When the P value of the Q-test was <0.1, or when I2 was >50%, it represented heterogeneous between studies.


 > Results Top


Study selection and description

After an electronic database searching, a total of 150 studies were yielded. Two investigators reviewed and determined whether these studies met the inclusion criteria. Finally, 10 papers on the evaluation of oncologic outcomes of TLM for recurrent early laryngeal carcinoma after previous treatment were included in this meta-analysis.[15],[16],[17],[18],[19],[20],[21],[22],[23],[24] The flow chart for searching strategy is exhibited in [Figure 1].
Figure 1: Flow diagram for study searching

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The characteristics of all these 10 studies, such as the demographics of the enrolled patients, their previous treatment, and the clinical stage of recurrence tumor were listed in [Table 1], as well as the quality scores of these included studies judged from allocation, blindness, and completeness.
Table 1: The characteristics of included studies

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Local control

A total of 8 studies reported the local control rate after the first TLM for patients with previous treatment failure. The pooled OR for local control from three studies was 3.08 (95% CI, 1.88–5.05), OR for 3-year local control was 1.57 (95% CI, 0.96–2.57), and OR for 5-year local control was 1.31 (95% CI, 0.81–2.12), suggesting no difference between 3-year and 5-year local control [Figure 2]. The high I2 value of 65% was shown, indicating the high degree of heterogeneity between studies.
Figure 2: Forest plot for OR of 3-year and 5-year local control rate. OR = odds ratio

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Overall survival

9 out of 10 studies recorded 5-year OS rate, and the pooled OR for 5-year OS was 2.29 (95% CI, 1.42–3.67), whereas the pooled OR for 3-year OS was 2.36 (95% CI, 1.52–3.67) based on 5 studies [Figure 3]. The I2 value for OS was still high, 68%, suggesting the heterogeneity across studies.
Figure 3: Forest plot for OR of 5-year and 3-year OS. OR = odds ratio, OS = overall survival

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Disease-specific survival

A total of 9 studies exhibited 5-year DSS rate and the pooled OR for 5-year DSS was 5.22 (95% CI, 2.75–9.91). The pooled OR for 3-year DSS was 3.25 (95% CI, 1.62–6.52) based on 4 studies [Figure 4]. Again, a high degree of heterogeneity across studies was shown (I2 = 73%).
Figure 4: Forest plot for OR of 5-year and 3-year DSS. OR = odds ratio, DSS = disease specific survival

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Organ preservation

Seven studies calculated the organ preservation rate after TLM treatment, and the pooled OR for larynx preservation was 3.82 (95% CI, 2.46–5.94, I2 = 44%), indicating a moderate heterogeneity between studies [Figure 5].
Figure 5: Forest plot for OR of larynx preservation after TLM treatment. OR = odds ratio, TLM = trasoral laser microsurgery

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Local recurrence

Six studies reported the local recurrence after the first TLM treatment, and the pooled RD was 45% (95% CI, 26–64%, I2 = 89%), suggesting a high heterogeneity across studies [Figure 6].
Figure 6: Forest plot for RD of local recurrence after TLM treatment. RD = risk difference

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Postoperative complications

A total of 10 patients developed with laryngeal stenosis, 7 with edema, and 4 with endolaryngeal hemorrhage after TLM procedures (data not shown).


 > Discussion Top


Traditionally, total laryngectomy was recognized as the primary option for radiorecurrent laryngeal cancer with good control rates.[25],[26] Given that higher incidence of postoperative complications, patients, and surgeons are more reluctant to adopt less radical and invasive procedures. Since TLM introduced in 1972, it has been well proven the contribution in the management of primary laryngeal cancer. In the last decades, more studies deal with the application of TLM in the recurrent setting regardless of the previous treatment. Based on our inclusion criteria, 10 studies fulfilled these criteria and included for this systematic review. To our knowledge, this is the first meta-analysis to assess the oncologic and functional outcomes of TLM in the context of recurrent early laryngeal cancer no matter what the previous treatment was.

In this analysis, the pooled ORs and RDs for main outcomes were calculated based on the extracted information from 10 included studies, the results of which indicated a favorable efficacy of TLM in local control, OS and DSS. Notably, TLM procedures presented outstanding larynx preservation for recurrent laryngeal cancer which was the major consideration for patients. Local control rate for recurrent laryngeal cancer may be influenced by the identification of the tumor borders attributed to different patterns of tumor growth such as submucosal spread and multifocal development. However, these situations are not contraindications to TLM, for complete tumor excision can be achieved by frozen sections on surgery or from suspicious areas with the repeated resection in the sequential operation.[20]

It has been demonstrated previously that anterior commissure involvement of recurrent laryngeal cancer was a contraindication to laser resection due to disappointing results on local control.[27] Although most of included studies reported the involvement of the anterior commissure, it seemed that it cannot come to the conclusion whether loco-regional control and survival rates were influenced by the involvement of anterior commissure.

Almost all the enrolled studies were retrospective, except that Grant et al. reported a two-center prospective case series analysis.[21] Additionally, high heterogeneity across the studies was maintained through the whole meta-analysis, which was attributed to the loss of control for TLM, and it is uneasy to compare other treatment with TLM, for that adequate transoral access is necessary for TLM. High heterogeneity would limit the applicability of the findings. Moreover, the conclusions of this meta-analysis cannot yet be extrapolated to the treatment for advanced tumors (rT3–rT4), although 5 of included studies recruited advanced local recurrent laryngeal cancer with limited oncological information and 2 studies evaluated local control and survival rate between early and advanced recurrences.

Based on our meta-analysis, TLM is a potentially effective option for recurrent early laryngeal cancer afterfirst treatment failure. In the future, more prospective studies are needed for confirmation the results of this study, and for the systematic comparisons between open partial laryngectomy and TLM.


 > Conclusions Top


TLM treatment for recurrent laryngeal carcinoma exhibited high incidence of OS, local control rate, and organ preservation, along with a moderate value of local recurrence, indicating that TLM is an effective option for relapse laryngeal cancer after primary therapies. However, more prospective clinical trials are needed to confirm its efficacy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

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Taylor SM, Kerr P, Fung K, Aneeshkumar MK, Wilke D, Jiang Y, et al. Treatment of T1b glottic SCC: Laser vs. radiation – A Canadian multicenter study. J Otolaryngol Head Neck Surg 2013;42:22.  Back to cited text no. 1
    
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Canis M, Martin A, Ihler F, Wolff HA, Kron M, Matthias C, et al. Transoral laser microsurgery in treatment of pT2 and pT3 glottic laryngeal squamous cell carcinoma – Results of 391 patients. Head Neck 2014;36:859-66.  Back to cited text no. 5
    
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Hinni ML, Salassa JR, Grant DG, Pearson BW, Hayden RE, Martin A, et al. Transoral laser microsurgery for advanced laryngeal cancer. Arch Otolaryngol Head Neck Surg 2007;133:1198-204.  Back to cited text no. 7
    
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Huang J, Yu Z, Fang J, Chen X, Chen X, Huang Z. Salvage transoral laser microsurgery for early recurrent glottic carcinoma after primary laser treatment. Acta Otolaryngol 2013;133:531-7.  Back to cited text no. 16
    
17.
Han YJ, Lee HS, Kim SW, Hong JC, Kim ST, Park HS, et al. Transoral laser microsurgery of recurrent early glottic cancer after radiation therapy: Clinical feasibility and limitations. Ann Otol Rhinol Laryngol 2012;121:375-82.  Back to cited text no. 17
    
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Del Bon F, Piazza C, Mangili S, Redaelli De Zinis LO, Nicolai P, Peretti G. Transoral laser surgery for recurrent glottic cancer after radiotherapy: Oncologic and functional outcomes. Acta Otorhinolaryngol Ital 2012;32:229-37.  Back to cited text no. 18
    
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Roedel RM, Matthias C, Wolff HA, Schindler P, Aydin T, Christiansen H. Transoral laser microsurgery for recurrence after primary radiotherapy of early glottic cancer. Auris Nasus Larynx 2010;37:474-81.  Back to cited text no. 19
    
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21.
Grant DG, Salassa JR, Hinni ML, Pearson BW, Hayden RE, Perry WC. Transoral laser microsurgery for recurrent laryngeal and pharyngeal cancer. Otolaryngol Head Neck Surg 2008;138:606-13.  Back to cited text no. 21
    
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Ansarin M, Planicka M, Rotundo S, Santoro L, Zurlo V, Maffini F, et al. Endoscopic carbon dioxide laser surgery for glottic cancer recurrence after radiotherapy: Oncological results. Arch Otolaryngol Head Neck Surg 2007;133:1193-7.  Back to cited text no. 22
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
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