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BY

Mohammed Ibrahim Helaley Helaley

Background Laryngeal carcinoma is the eleventh-most common form of cancer among men worldwide and is the second-most common malignancy of the head and neck.

Laryngeal cancers account for almost one fourth of the approximately 45,000 head and neck malignancies diagnosed in 2007 in the United States .

Supraglottic and glottic tumors are the most common subsites, and subglottic carcinomas are uniformly rare. In the United States, glottic carcinomas are the most common (glottic, 59%; supraglottic, 40%; subglottic, 1%). Eighty-five percent of laryngeal cancers can be attributed to tobacco and alcohol use. Smoking is the predominant risk factor for laryngeal carcinoma with alcohol use being an independent and synergistic risk factor.

Glottic cancer staging :

Tumor stage Tis T1 Carcinoma in situ. Tumor limited to vocal cord(s) (may involve anterior or posterior commissure) with normal mobility. T1a :Tumor limited to one vocal cord. T1b :Tumor limited to both vocal cord. Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility. Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space, and/or inner cortex of the thyroid cartilage. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx . Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures. Characteristics

T2

T3

T4a T4b

The appropriate definition of the term early as it applies to laryngeal cancer has been debated. A laryngeal cancer is considered early if it can be treated by partial laryngeal (conservative) surgery without a neck dissection, by endoscopic excision, or by radiotherapy alone.
Early-stage glottic cancers are defined as stage 0, I, or II disease. By definition, early-stage glottic cancers lack regional lymph node involvement or distant metastasis.

The main presentation is hoarseness. Even carcinoma in situ may produce significant voice change.

The typical patient is a male in his 50s or 60s with a history of smoking and/or alcohol use.

The male predilection for this disease has recently decreased from a male: female ratio of 15:1 to currently less than 5:1.

Diagnosis 1-Careful history taking 2-Good examination of larynx, head and neck 3-Imaging (CT, MRI) 4-Endoscopy and biopsy

Treatment
Glottic laryngeal squamous carcinoma in its early stages has an excellent prognosis. The disease can be effectively treated by external beam radiotherapy, conservative open laryngeal surgery or endoscopic excision using cold techniques or CO2 laser.

Laser microsurgery has become an established time-efficient treatment option for early laryngeal cancer .Laser resection provides more therapeutic options for management of persistent or recurrent disease. Radiotherapy offers the benefits of no surgery and has good local control and survival rates.

Open surgical procedures for early glottic cancers can be regarded as organ preservation procedures because they aim to preserve speech and swallowing without a permanent stoma.
Several open surgical laryngeal procedures are available for the treatment of early glottic cancers. It includes laryngofissure with cordectomy, vertical partial hemilaryngectomy and supracricoid laryngectomy.

Each treatment modality appears to produce similar disease-free survival figures and control of the disease at the glottis in 8095% of the cases.

Given that there is equality of survival between the treatments, other factors must also be considered in determining treatment, particularly quality of life and cost.

Because of the importance of voice in determining a patients quality of life, it is necessary to examine this issue .
Voice analysis includes subjective patient satisfaction scales, perceptual evaluation, and objective measures.

Measuring voice is accomplished using acoustic analysis, aerodynamic assessment, and source measures.

Aim of the work

The purpose of this study is to analyze voice outcome measures after treatment of early glottic carcinoma, in order to determine the impact of various treatment modalities on voice.

Materials and methods

This will be done by the following steps: 1. Target question. 2. Identification and location of articles. 3. Screening and evaluation of articles. 4. Data collection. 5. Data analysis. 6. Reporting and interpretation. 7. Discussion and conclusions.

1) Target question
What are the outcomes measures of voice following various treatment modalities of early glottic

carcinoma ?

2) Identification and location of articles

The study includes published medical articles concerning management of early glottic carcinoma. The search was limited to prospective articles published in the last 20 years in English language ,conducted on human subjects in Pubmed (Medline data base). The search was done on 11\1\2010.

The following table summarizes the results of the search:

Keywords early glottic cancer glottic cancer glottic cancer radiotherapy glottic cancer surgery glottic cancer laser Number of articles and their abstracts 33 122 49 102 33 Number of relevant articles 6 19 7 16 6

glottic cancer treatment

glottic carcinoma treatment voice laryngeal cancer treatment voice

116
25 85

21
17 27

voice outcome after glottic cancer surgery

13

Relevant articles were 124, by removing repeated articles; the total relevant articles are 28.

3) Screening and evaluation Articles published in Pubmed included will be screened to report on at least: A. Patients with early glottic carcinoma. B. Adequate number of patient (10 cases). C. Intervention (surgery, laser, radiotherapy). D. Pre and post treatment objective voice analysis . E- We included only prospective and controlled articles.

All searches for early glottic carcinoma yielded 28

relevant articles, of which only 5 articles were

included. 2 articles had radiotherapy as an

intervention, 2 articles had surgery as an intervention,

and 1 article had laser as an intervention.

4) Data Collection :
For (5) Included articles the following will be recorded in a data collection form :
Author /Year Level of evidence Intervention participants Voice outcome

Bibby et al,2007
III radiotherapy

30 pt 21 T1NOMO 9 T2NOMO

Fundamental frequency, Jitter, Shimmer, MPT,HNR .

Kazi et al,2008

III

radiotherapy

25 pt 18 T1N0 , 7 T2N0 85 pt 16 Cis, 50 T1a, 19 T1b 15 pt T2 tumors 23 pt T1a tumors

Fundamental frequency, Jitter, Shimmer, MPT.

Roh et al,2006

III

Laser cordectomy

Fundamental frequency, Jitter, Shimmer, MPT,HNR .

Dursun and Ozgursoy ,2005 Biacabe et al,1999

III

vertical partial laryngectomy

Fundamental frequency, Jitter, Shimmer, HNR .

III

vertical partial laryngectomy

Fundamental frequency, Jitter, Shimmer, MPT,HNR .

Causes for exclusion of other 23 articles author Cause of exclusion

Portas et al.,2009

Only postoperative subjective voice analysis.

advanced glottic cancer was included with no seperate outcome

Taylor and Rigby, 2008

Basterra et al.,2006

postoperative subjective voice analysis

Only postoperative subjective voice analysis

Martins et al.,2005

Only postoperative objective and subjective voice analysis

Makeieff et al.,2005 Luna-Ortiz et al.,2004

Only postoperative objective and subjective voice analysis

- Only postoperative objective voice analysis - advanced glottic cancer was included with no separate outcome

Zeitels et al.,2002

Only postoperative objective voice analysis.

Bron et al.,2002

Only postoperative subjective and objective voice analysis . T3, T4 was included with no separate outcome

Weinstein et al., 2001

Postoperative subjective voice analysis Stages of patients was not determined

Biacabe et al.,2001 The Postoperative voice analysis according glottic closure.

Stoeckli et al.,2001 Modrzejewski et al.,1999

Postoperative subjective voice analysis Postoperative objective voice analysis Stages of patients were not determined.

Verdonck-de Leeuw No recorded pre and post treatment data. et al.,1999 Sittel et al.,1998 Postoperative objective voice analysis

Stewart et al.,1998

Other than glottic cancer was included no separate results.

T3, T4 included with no separate results.

Only Postoperative subjective voice analysis.

Crevier-Buchman et T3 included with no separate results. al.,1998

Reino et al, 1997

Only Post operative objective voice analysis. Advanced glottic cancer included with no separate results.

Crevier-Buchman et Only 3 patients was included al,1995 Only Post oprative voice analysis. Laccourreye et al.,1995 Laccourreye et al.,1995 Only Post opeerative objective voice analysis.

Only Post operative objective voice analysis

Salam et al.,1992

Postoperative subjective voice analysis. T3 included with no separate results

Harrison et al.,1990

Pre and post treatment determination of percent voicing (%V) (normal = presence of phonation = 90-100%V) (no recorded data).

Miller et al.,1990

Pre and post treatment determination of voicing ratio (no recorded data).

5) Data Analysis 1-Pre and post treatment Fundamental frequency:

Voice hypofractionat Laser outcomes ed after radiotherapy radiotherapy Gp A Laser Laser vetical vetical laryngectom laryngecto-y my Laryngeal reconstruction

Gp B

Gp C

Gp A

Gp B

Pre treatment 189.00 170.2 151 179 158 143 156 169.493

Post treatment 157.82 142.7 132 162 165 143 170 162.495

2-Pre and post treatment jitter:

Voice hypofractionat Laser Laser outcomes ed after radiotherapy radiotherapy Gp A Gp B Laser vetical vetical Laryngeal laryngectom laryngectom reconstructio -y -y n Gp A Gp B

Gp C

Pre treatment 6.71 0.97 4.1 5.6 5.9 1.7 3.4 3.884

Post treatment 3.27 0.31 1.5 3.5 4.8 5.8 7.5 8.894

3-Pre and post treatment shimmer:

Voice hypofractionat outcomes ed after radiotherapy radiotherapy Laser Laser Laser vetical laryngectom -y GpA vetical laryngectom -y Gp B Laryngeal reconstructio n

Gp A

Gp B

Gp C

Pre treatment 1.9 0.98 10.8 14.4 12.4 8.6 11.9 12.93

Post treatment 1.35 0.67 4.9 8.8 9.4 14.3 17.5 18.485

4-Pre and post treatment H :N ratio:

Voice outcomes after radiotherap y hypofractiona ted radiotherapy Laser Laser Laser vetical vetical Laryngeal laryngectom laryngectom reconstructio y y n Gp A Gp B

Gp A

Gp B

Gp C

Pre treatment 2.77 ===== 16.7 14.9 13.3 18 31 0.46

Post treatment 4.3 ==== 20.6 17.1 17.4 33 47 0.693

5-Pre and post treatment MPT:

Voice outcomes after radiotherap y hypofractionat Laser Laser ed radiotherapy Gp A Gp B Laser vetical vetical Laryngeal laryngectom laryngectom reconstructio y y n Gp A Gp B

Gp C

Pre treatment 9.59 14.8 13.5 14.4 13.7 13.1 11.2 ====

Post treatment 12.16 16.4 13.8 11.7 11.3 6.7 6.8 ====

6) Reporting and interpretation (Results)

1-Pre and post treatment Fundamental frequency:

2-Pre and post treatment jitter:

3-Pre and post treatment shimmer:

4-Pre and post treatment H:N ratio:

4-Pre and post treatment MPT:

7) Discussion Although the principal objective of oncology

treatment is the complete eradication of the illness,

normal voice preservation is another important

consideration in the treatment choice of early glottic

carcinoma. For this reason, post-treatment voice

quality is a relevant factor to take into account when

evaluating the results.

In our study we collected data by searching for medical articles concerning management of early glottic carcinoma. The search was limited to articles published in English language, conducted on human subjects in PubMed (Medline data base). All searches for early glottic carcinoma yielded 124 relevant articles, by removing repeated articles; the total relevant articles are 28, of which only 5 articles were included. 2 articles had radiotherapy as an intervention, 2 articles had surgery as an intervention, and 1 articles had laser as an intervention.

In radiotherapy groups, both acoustic and aerodynamic measures demonstrated improvement from pretreatment to post treatment. Improvement in acoustic voice measures may be attributed to removal of the tumor mass and irregularities from the vocal folds. Patients improvement in MPT indicated greater respiratory and laryngeal control after treatment .

Voice quality is likely to be good after laser surgery limited to submucosal and subligamental resection. Voice quality after transoral laser excision is closely associated with extent of resection. Poor voice quality after laser cordectomy as the type of cordectomy increases was due to reduced volume, mobility, and mucosal wave and increased scarring of the

preinjured vocal folds.

Surgery groups had the worst voice quality in comparison

to other groups.
Increased fundamental frequency is due to resection of the true vocal cord and a wide portion of the paraglottic space . The other results after surgery are related to unstable vibrational incomplete characteristics glottic of the neoglottis and

closure

following

surgery.

Conclusion 1- Radiotherapy results show that there is marked improvement in voice from pretreatment to Post treatment. 2- Voice quality is likely to be good after laser excision but as the extent of laser excision increases for larger tumors, voice quality is likely to deteriorate.

3- Patients with glottic reconstruction have good voice quality in comparison with patients without glottic reconstruction.

4- Voice after radiotherapy had superior voice quality than laser cordectomy in which post treatment voice is deteriorate as the extent of laser excision increases. The voice after surgery had the least quality of voice.