ORIGINAL ARTICLE
ENDOSCOPIC HORIZONTAL PARTIAL LARYNGECTOMY BY CO2 LASER IN THE MANAGEMENT OF SUPRAGLOTTIC SQUAMOUS CELL CARCINOMA Francesco Bussu, MD,1 Giovanni Almadori, MD,1 Eugenio De Corso, MD,1 Davide Rizzo, MD,1 Mario Rigante, MD,1 Claudio Parrilla, MD,1 Vincenzo Valentini, MD,2 Gaetano Paludetti, MD1 1 2
Institute of Otorhinolaryngology, Universita` Cattolica del Sacro Cuore, Rome, Italy. E-mail:
[email protected] Institute of Radiotherapy, Universita` Cattolica del Sacro Cuore, Rome, Italy
Accepted 12 December 2008 Published online 9 April 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.21085
Abstract: Background. The objective of this study was to evaluate the results of endoscopic horizontal supraglottic laryngectomy (EHSL) by CO2 laser. Methods. Between 1996 and 2005, 78 patients underwent a horizontal supraglottic laryngectomy operation (HSL) with an external approach and 70 underwent laser EHSL, as treatment for supraglottic laryngeal squamous cell carcinoma (LSCC). We evaluated oncological endpoints, comparing the external and the endoscopic approach. Results. Among patients primarily treated by EHSL, the 5year disease-specific survival (DSS) was 89% (vs 80% in the external approach group). Statistical analysis did not reveal significant differences between the 2 groups as for survival nor for organ preservation. The most significant clinical predictor for DSS is neck relapse (p < .0001). Conclusions. This study confirms the effectiveness of laser EHSL in which oncological outcome is similar to the external approach and functional results are probably better. Neck management in this setting is fundamental to warrant the best C 2009 Wiley Periodicals, Inc. Head Neck 31: survival. V 1196–1206, 2009 Keywords: supraglottic cancer; disease specific survival; salvageability; CO2 laser; horizontal supraglottic laryngectomy
Correspondence to: F. Bussu C 2009 Wiley Periodicals, Inc. V
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Nowadays, more than ever before, in clinical oncology a premium is placed on returning the patient to a productive and useful lifestyle (ie, quality of life after cancer treatment). This attitude is demonstrated more keenly in the treatment of laryngeal cancer than with almost any other malignancy. In the past, treatment of laryngeal cancer focused predominantly on cure by relentless surgical aggressiveness. At present, swallowing, phonation, breathing, and aesthetic appearance of a patient treated for laryngeal cancer are relevant endpoints. This led to the emergence of conservative strategies, both surgical, with the codification of partial operations, and nonsurgical, with a variety of combinations and sequences of chemotherapy and radiotherapy, with the common aim of organ preservation.1–3 During the last 3 decades, the treatment options and their sequencing have thus radically changed. As a result, the overall 5-year survival rate (65%–66%) for patients with laryngeal squamous cell carcinoma (LSCC) has not significantly improved4–6; nevertheless, a higher percentage of contemporary patients are probably retaining their larynx. HEAD & NECK—DOI 10.1002/hed
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During the period between 1996 and 2005, 144 patients (129 men and 15 women) underwent a supraglottic partial laryngectomy in the Depart-
ment of Otolaryngology and Head and Neck Surgery of Universita` Cattolica del Sacro CuorePoliclinico Gemelli, in Rome, as primary treatment for supraglottic laryngeal squamous cell carcinoma (SCC). Of these patients, 66 patients (60 men and 6 women) were operated on endoscopically by CO2 laser. Other 4 patients underwent endoscopic supraglottic laryngectomy for primary tumor persistence/recurrence after irradiation (in 3 cases with concomitant chemotherapy), with no residual/recurrent disease in the neck: 3 of them were T1 of the epiglottis and 1 was T2 of the epiglottis and of the false vocal fold. This small group could not be subjected to a detailed statistical analysis, but we are going to describe it separately in the present article because it may retain useful information as well. All clinical and pathological data were reviewed retrospectively. The age of the primary patient cohort ranged from 39 to 78 years, with a mean age of 60.7 years, a normal distribution (p ¼ .0207 at Shapiro-Wilk W Test), and a peak of incidence in the first half of the seventh decade. Follow-up duration ranged from 1 to 236 months, with an average follow up of 60 months. We do not observe statistical significant differences as for age distribution and follow-up duration between the patients operated on with the endoscopic and the external approach. Preoperative staging of the tumor was carried out by endoscopy (indirect laryngoscopy, videolaryngoscopy) and CT of the neck to evaluate cartilage and lymph node involvement. In the last 3 years, we performed an MRI scan in doubtful T2 cases, to assess preepiglottic space involvement, potential initial cartilage involvement, and therefore the feasibility of a radical endoscopic resection. All patients were restaged retrospectively according to the Union Internationale Contre le Cancer (UICC) staging system (TNM-2002). We considered radically resectable with supraglottic laryngectomy T1, T2, and T3 (only for preepiglottic invasion) cases, with the involvement of not more than 1 arytenoid and without an extensive involvement of the medial wall of the piriform fossa or of the preepiglottic space. The indication for transoral laser CO2 surgery was fulfilled if the tumor was completely exposable during the previous diagnostic microlaryngoscopy with multiple biopsies. Transoral surgery was performed using a Sharplan CO2 laser, mounted on a Zeiss surgical microscope and generally set to an output power
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In the supraglottis, lesions are more likely to be nonkeratinizing and poorly differentiated, and they have more aggressive behavior in general, than in the glottis. Because of the profuse lymphatic network of the supraglottic larynx, carcinomas of this area metastasize frequently to the cervical lymph nodes, and failure usually results from metastasis rather than local relapse.7–9 The incidence of patients with clinically positive lymph nodes at the time of diagnosis is 23% to 50% for all supraglottic sites and stages combined.10–13 Yet, a substantial number of those patients with clinically negative necks turn out to have histologic disease as demonstrated when a neck dissection is done or, if left untreated, they convert to clinically positive necks.14,15 Anyway, much of the data on clinically positive necks and on occult metastasis were compiled before the routine use of CT and MRI of the neck. These more sophisticated staging methods are added to the already 75% to 85% accuracy of physical examination16; at present in our institution, the overall incidence of metastases noted at the time of diagnosis is probably higher and false negatives are less frequent than 30 years ago. Primary treatment protocols in the management of supraglottic cancer may include surgery or radiotherapy as single modality or as part of a combined treatment.17 If patients are carefully selected, in early stages, the 2 single modalities appear associated with comparable oncological outcome and with comparable functional outcome. To add useful information about the functional and oncological results of the horizontal supraglottic laryngectomy (HSL) operation in the treatment strategy for T1, T2, and T3 laryngeal supraglottic cancers, we retrospectively evaluated our series of 148 patients comparing the endoscopic and external approach. Focusing on the peculiarity of the endoscopic approach (EHSL) by CO2 laser, we evaluated oncological endpoints as overall survival, disease-specific survival, local and regional relapse-free survival (RFS), and functional endpoints as the recovery of swallowing function, the need for tracheotomy and the organ preservation rate (need for total laryngectomy).
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of 4 W, in super pulse mode, and a spot of 0.6 mm. With these settings, the laser light is emitted in pulses, with a peak power of 60 W, at a frequency of 60 Hz and represents a good cutting tool. The tumors were resected en bloc and the excised tissues were whole-mounted on a slide and oriented by marking margins. Further seriate biopsies were always performed by cold instruments on the surgical bed after the resection, to obtain more reliable information about the margins. As for the surgical technique, we conformed to the standard endoscopic supraglottic laryngectomy by CO2 laser as already described elsewhere.18 After complete resection of the tumor, the wound was always left open to heal by secondary intention. Our attitude about the N0 neck became more aggressive in the last years, and at present we adopt a ‘‘wait and see’’ policy only in selected T1 with a presumed good compliance to a strict follow-up; in the other cases, we perform the neck dissection or recommend, in patients with poor general condition, a prophylactic irradiation (usually 50 Gy). In the series described in the present article, we had a large group in which a ‘‘wait and see’’ policy was adopted as well, and we analyzed the oncological endpoints also in this group. We recorded both clinical and pathological staging (as for the neck, only when available). Follow-up data were collected through visits in our department by indirect laryngoscopy or videolaryngoscopy (every 2 months during the first year, every 3 months during the second, every 4 months during the third, and twice a year successively). In the first year, we recommend a CT scan of the neck every 4 months, in the second year every 6 months; we suggest a chest CT every year in the follow-up because lung second primary tumors (SPTs) are the first cause of death in patients with early stage tumor of the larynx.19 In the follow-up, incisional biopsies under direct microlaryngoscopy were often performed electively 1 month after the first surgical approach, in bulky cases, and whenever relapses were suspected. Function was evaluated, in all the 70 patients (with primary SCCs and recurrences) treated by an endoscopic approach, based on retrospective analysis of the following parameters: timing and extent of swallowing recovery, need for nasogastric feeding tube and/or gastrostomy and timing and extent of breathing recovery, need for a tracheotomy.
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Statistical analysis was performed using the JMP in software, release 5.1, by the SAS Institute. Survival curves were calculated since the day of first diagnosis by the Kaplan-Mayer method. For comparison of survival curves, we used both log-rank and Wilcoxon tests. The alpha level was fixed at 0.05 for all the statistical tests we performed.
RESULTS Comparing External and Endoscopic Approach. We did not observe statistically significant differences as for T and N classification distribution or grading between the endoscopic and external approach groups. Instead, the site of origin and the involved regions varied significantly, as these parameters definitely influenced the surgical planning (Table 1). The extent of the resection is standardized in the external technique, which has been adapted to the extension of the tumor in the endoscopic approach (Table 2). Statistical analysis did not reveal significant differences between the 2 groups as for overall survival (OS), disease-specific survival (DSS) (Figure 1), local RFS, or organ preservation rate (need for total laryngectomy). We had 8 local recurrences in the ‘‘endoscopic’’ (12%), 7 in the ‘‘external’’ group (9%); in all but 1 case in the ‘‘external’’ group, we were able to perform a total laryngectomy for salvage. Disease-specific survival is not statistically different between patients with a local recurrence after external and endoscopic approach (Figure 2), even if it is slightly better in the latter group. It may give us an idea of the local salvageability.
Outcome Predictors in the Endoscopic Approach Group. We performed a neck dissection at the time of primary treatment in 39 cases, comprehensive on 15 clinically involved sides (13 type III modified radical, 1 type II modified radical, 1 radical neck dissection), elective selective of levels II, III, IV (lateral neck dissection) in the others. Selective neck dissection was bilateral in 15 cN0 cases which approached the midline and contralateral to the lesion when the other side was clinically involved (and underwent a comprehensive neck dissection). Postoperative radiotherapy at a dosage of 50 to 60 Gy was performed after primary conservative surgery in 26 patients out of 66 (39.4%), in case of positive
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Table 1. Distribution by clinical T and N classification and by involved subsites in primary supraglottic squamous cell carcinomas. T classification Endoscopic approach T1 T2 T3 External approach T1 T2 T3 Involved subsites
N0
N1
N2a
N2b
N2c
Total
11 30 10
0 2 0
0 2 0
0 5 2
2 1 1
13 40 13
15 30 7
2 4 2
0 2 1
3 6 3
0 2 1
20 44 14
Endoscopic approach
External approach
7 60 7 22 14 6
68 23 15 17 19 1
Infrahyoid epiglottis Suprahyoid epiglottis Arytenoid Aryepiglottid fold Ventricular band Base of tongue
margins, pN >1, and in pN >0 when an extracapsular spread was evidenced (Table 2); in the present series, we never performed prophylactic radiotherapy as an elective treatment for cN0 neck. We evaluated all the clinical and pathological variables under examination in relation with the oncological endpoints, considering DSS more relevant than overall survival (OS). Local RFS and regional metastasis-free survival (MFS), respectively, were 72% and 75% at 5 years. The most significant clinical prognostic marker is neck node relapse which markedly influences disease-specific survival (p < .0001 at log-rank and at Wilcoxon tests), patients with a regional relapse in any moment of their clinical history have a 5-year DSS of 50%. As expected local relapse predicts a shorter DSS as well (p ¼ .0002 at log-rank and p ¼ .0003 at Wilcoxon tests), patients with a local relapse in any moment of their clinical history have a 5-year DSS of 64%. This also gives an idea of the salvageability of local recurrences in patients who
underwent EHLS. Even more meaningful, in our opinion, is the observation that local recurrences (8/66) were all susceptible to salvage laryngectomy and that only 1 of them died for another local recurrence. Salvage neck dissection has been performed when the original clinically N0 became clinically positive (10 patients out of 51: 19.6%), 6 of them died of disease and 5 because of neck metastases (only 1 for local relapse). To evaluate the relevance for survival of nodal involvement at diagnosis is not simple, in a group in which the management of the nodes has not been homogeneous: in particular, cN0 cases underwent selective neck dissection or alternatively observation; therefore, in many cases, we had not the pN (the real one) at diagnosis. Therefore, we performed several different statistical analyses trying to obtain useful information about the most useful attitude for the patients. We compared the DSS and the MFS of patients who underwent neck dissection (including clinical N0 and Nþ) with cN0 patients who
Table 2. Treatment modalities related to clinical stage in the endoscopic group. Supra glottic cancer (66pts) cT1-2 N0 Epiglottidectomy EHSL EHSL þ ND EHSL þ ND þ RT
cT3 N0 8 pts 19 pts 8 pts 6 pts 41 pts
EHSL þ ND EHSL þ ND þ RTon N EHSL þ ND þ RTonN –T (2 pts R1)
cT1-3 Nþ 5 pts 3 pts 2 pts
EHSL þ ND EHSL þ ND
þ RT on N þ RT on N – T (4 pts R1)
10 pts
11 pts 4 pts
15 pts
Abbreviations: EHSL, endoscopic CO2 laser horizontal supraglottic laryngectomy; ND, neck dissection; RT, postoperative radiotherapy.
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FIGURE 2. Comparing disease-specific survival (DSS) in patients with local recurrence after the endoscopic (5-year DSS 64%) and external approach (5-year DSS 55%). No statistically significant differences were found even if patients with recurrence after an endoscopic approach have a slightly better DSS (p value at log-rank test ¼ .6087).
77%, in the nondissected group (Figure 5). The differences between the curves are not statistically significant (probably for the low number of cases) but a trend can be evidenced (p ¼ .08 for MFS at log-rank test in the whole group). The
FIGURE 1. Comparing overall survival (OS) and disease-specific survival (DSS) after the endoscopic (5-year OS 75%, 5year DSS 89%) and external approach (5-year OS 80%, 5-year DSS 80%). OS and DSS do not differ significantly between the 2 groups (at log-rank test p ¼ .8324 and .1581, respectively).
did not undergo neck dissection; even if statistically significant differences could not be detected, the trend toward a better survival (at log-rank p ¼ .1314 in DSS curve, p ¼ .1447 in MFS curve), for patients primarily dissected, deserves regard in the discussion. No differences in DSS and in MFS were observed between patients with and without clinical nodal involvement at diagnosis (Figure 3). If we consider only cN0 patients at diagnosis (including also who resulted pNþ at histopathology), we had a 100% disease specific and MFS when we performed an elective selective neck dissection, which decreases to, respectively, 83% and 74% in nondissected patients (Figure 4). When considering the whole group of patients (including also those treated by an open approach) with cN0 supraglottic SCC, the 5year DSS was 91% and the MFS 100% in the dissected group versus, respectively, 80% and
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FIGURE 3. Comparison of DSS (A) (p at log-rank test ¼ .3319) and MFS (B) (p at log-rank test ¼ .9303) between cN0 (dotted line) and cNþ patients at diagnosis.
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radiotherapy, which is probably useful in reducing local recurrence rate. We had only 3 cases of distant metastases, 2 in the lungs, 1 in the bones (vertebrae and femur), all in patients with massive neck recurrence, who could not anyway be salvaged for the regional relapse. Oncological
Outcome
in
the
Salvage
EHSL
We obtained a resection without residual tumor in all the 4 patients. They are all alive and well. The recurrence (or, more properly, the persistence) after radiotherapy was always diagnosed by biopsies under microlaryngoscopic view within 100 days since the end of the radiotherapy. Group.
We had to perform a tracheotomy in less than one half (30) of our patients not previously irradiated (45%) undergoing an EHSL, whereas we always perform a tracheotomy in case of external approach. All patients salvaged for a local recurrence after radiotherapy
Functional Results.
FIGURE 4. Analyzing the ‘‘endoscopic’’ group: comparison of DSS (A) (p at log-rank test ¼ .3778) and MFS (B) (p at logrank test ¼ .2828), between electively dissected (dotted line) and nondissected cN0 patients.
rate of pathological nodal involvement (pN1 or pN2b) in the cN0 dissected necks is about 18%. Finally, we analyzed the prognostic role of pathological neck involvement in the group of dissected patients. We did not find statistically significant differences in DSS between pN0 and pNþ patients; anyway, we observed a nonsurprising trend toward a shorter MFS in patients with pathological node involvement. Such trends were confirmed also when analyzing the whole population (including the patients treated by an open approach). According to TNM, we divided the patients in 3 groups (cT1-2N0, cT3N0, anyTNþ) without finding statistically significant differences as for DSS or for RFS. We obtained a resection without residual tumor in 60 patients (R0 resection), a R1 resection (with microscopic infiltration of margins) in 6 (9%) patients (5 of them were T3) (Table 2). There were not statistically significant differences between R0 and R1 patients in DSS or in RFS, anyhow cases with a microscopical infiltration of margins always underwent adjuvant
FIGURE 5. Analyzing the whole group of 144 patients with primary supraglottic SCC: comparison of DSS (A) (p at log-rank test ¼ .3513) and MFS (B) (p at log-rank test ¼ .08), between electively dissected and nondissected (dotted line) cN0 patients.
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underwent the tracheotomy. In the primary treatment of the endoscopic group, the tracheotomy (performed in 30 patients) was closed within 60 days in 53% of cases, sometimes on the occasion of a second microlaryngoscopic (with or without biopsies) view of the surgical bed 45 to 50 days after the operation. Only 1 patient, who sustained also adjuvant irradiation on the primary site for positive margins, has his tracheotomy open 2 years after surgery, for supraglottic stenosis unsuccessfully treated by CO2 laser. Of the remaining 45% of patients, most of which underwent radiotherapy as well, only 3 (10%), all postoperatively irradiated for positive margins, developed a stenosis which required laser surgery before tracheotomy closure. Therefore, adjuvant radiotherapy is associated to supraglottic stenosis in 4 of 26 cases, all irradiated on the primary site because of positive margins and to a longer rehabilitation time. As for the group of patients primary treated by an open approach, tracheostomy closure is usually delayed (average time of closure: 50 days), but, most of all it has been more often impossible because of stenosis, which occurred in 2 patients irradiated for neck metastases, and in 5 of 8 patients irradiated for positive or close ( 1) is surgery on T and N (monolateral or bilateral comprehensive neck dissection) plus adjuvant radiotherapy on N. Treatment planning in cN0 cases (cN0) is defi-
nitely more controversial.34,35 Advocates of the ‘‘wait and see’’ policy (treating only T in cN0 cases) assess that the increased sensitivity of imaging techniques is leading to a decrease of false-negative necks and to an earlier detection of neck recurrences (which can often be salvaged).36 An alternative option is to perform prophylactic irradiation of N0 necks. Anyway other surgeons perform a selective neck dissection of levels II, III, and IV (homolateral in lateral T1-2 cases, bilateral in the others), performing an adjuvant radiotherapy if pN >1 or in case of N1 with extracapsular spread, according with the main international guidelines.37–39 Another controversial issue is the timing of the elective neck dissection. Some authors perform the neck dissection in 1 time with the endoscopic horizontal supraglottic laryngectomy (EHSL). Neck dissections are performed later by Steiner et al, often at a time when a second look at the primary site can be accomplished. Third, few studies evaluated the role of EHSL as salvage treatment after the failure of radiotherapy. The common opinion is that it is associated to a lower local control and to a higher rate of complications. We did not find statistically significant differences, as for the oncological endpoints, between external and endoscopic approach, thus, confirming the value of the endoscopic CO2 laser surgery, compared with the conventional open procedure.18,22–27,40 The high rate of positive margins in T3 cases, even if does not outwardly draw on survival nor definitely contraindicates ESHL, emphasizes the importance of careful selection and that supraglottic carcinoma should be treated by trans-oral surgery only if R0 resection can be obtained.27 The indications for adjuvant radiotherapy, which usually emerge from histopathological findings on surgical specimens, are in our opinion the strongest support for an endoscopic versus an open approach. In fact, after an open approach, radiation oncologists are fairly reluctant to perform the radiation therapy when indicated, for the high rate of complications (in particular perichondritis), which not infrequently result in interruptions of treatment and eventually in total laryngectomy in the absence of residual disease. Although this reluctance can be overcome in case of neck metastases at the histopathological examination, and the
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irradiation can be accomplished with larynx shielding and a conformational or intensity modulated technique on the nodal echelons, irradiation remains a very risky procedure in case of positive margins, when it directly involves larynx. The lack of uniform guidelines for treatment selection at our institution along the years under study may be a weakness of the present work, because patients homogenous for T and N classification have been treated in a different way in different periods. The unhomogeneity of treatment selection probably originates the lack of significance of the stage related analysis, when comparing T1-2N0, T3N0, and anyTNþ groups. Nevertheless such unhomogeneity may also be a strength of the present work insofar as it allows us to evaluate the added variables and to obtain, if not unequivocal, for sure interesting statistical results, in particular concerning the neck, which is by far the main issue and the first cause of failure also in our study. In fact in our series, neck recurrence is the most significant prognostic parameter (low salvageability), the first cause of death (83% of deaths for disease) and there is a trend toward a better survival in dissected cN0 patients (Figure 4). Moreover, occult neck metastatic disease has been proven in 16% to 37% (17% of cN0 dissected cases in our series) of patients with no palpable nodes. In the last years, we have recommended an elective neck dissection in most cN0 cases, and the present results seem to confirm that we have been right. An alternative option is to perform prophylactic irradiation of cN0 necks. It can be a valuable choice in selected cases, for example, with a high anesthesiologic risk, but as a rule we prefer to treat supraglottic cancer with a single modality as long as it does not detract from our chances to control disease, as explained earlier. Only recently some authors suggested selective neck dissection in selected cases of cNþ necks.41–43 Even if we have no numbers or data to specifically address this issue, at present we do not perceive this as a safe behavior, because a single macroscopic node is possibly associated to smaller homolateral or even contralateral ones, which are not palpable but histologically positive; not to perform a comprehensive dissection detracts from our ability to correctly stage the disease and it frequently results in an undertreatment if we decide not to irradiate the
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neck, or alternatively in an overtreatment with an unnecessary multimodality strategy and unnecessary morbidity if we decide to perform adjuvant irradiation, basing in both cases on insufficient pathological information. In ours as in the other main institutions dealing with head and neck cancer, treatment choice is made by a multidisciplinary tumor board; in early supraglottic cancer, radiotherapy and surgery as primary treatment are associated with similar DSS rates,17 therefore, we select the first line treatment based on anatomy and site of the primary tumor, surgical issues (as the possibility to adequately expose the tumor), general health, and in particular pulmonary conditions, age, patient’s preference, and compliance. Diagnosis and treatment of the recurrence of laryngeal cancer in irradiated patients has been classically considered a tricky problem. In fact, diagnosis is often late, restaging is often inaccurate and salvage treatment is often total laryngectomy.44 In our institution, the close cooperation among otorhinolaryngology, radiology, radiotherapy, nuclear medicine departments leads to a close and effective follow-up, which allows us to diagnose early recurrences, staging them accurately: small T1-T2 supraglottic residuals seem to be suitable to a safe partial surgery with very promising preliminary results. The issues in these cases may be mainly functional, and also for this reason we think that the endoscopic approach, when possible, should be preferred. In fact, the described complications are probably more frequent in the external approach; our 4 patients retained their larynx and their voice and were able to feed without nasogastric tube or gastrostomy in 3 of 4 cases.
CONCLUSIONS
Our described experience with supraglottic squamous cell carcinoma allowed us to better define our institutional guidelines in this setting. Staging, treatment choice, and follow-up are a team work of the multidisciplinary tumor board. When anatomy and site of the primary tumor, the possibility to expose the tumor, and the pulmonary conditions are considered adequate, at present we advice an EHSL in T1, T2, and selected T3 (for initial preepiglottic invasion) supraglottic SCCs. In bulky tumors, in the case of ill-defined pathological margins
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and in all T3, we are inclined to give a ‘‘second look’’ to the surgical bed by a micro-laryngoscopy (with multiple biopsies) 1 month after the EHSL, to early detect residual disease. We always perform adjuvant radiotherapy on the larynx when resection margins are positive or close to the tumor. As regards the neck, in cNþ cases we perform a bilateral comprehensive neck dissection plus adjuvant radiotherapy on the neck in case of pN >1. For cN0 patients, we recommend a selective neck dissection of levels II, III, and IV (homolateral in lateral T1-2 cases, bilateral in the others), performing an adjuvant radiotherapy on the nodal echelons if pN >1, and if pN ¼ 1, in case of extracapsular spread or of monolateral dissection. In our opinion, this strategy warrants the best regional control also in case of inadequate preoperative staging and of low compliance to the follow-up by the patient. If we are planning a second look, if anesthesia is not particularly risky and if the patient is compliant enough to undergo without complaints a treatment program with 2 surgeries in about 2 months, we perform the elective neck dissection later (delayed neck dissection) as Steiner, on the occasion of the second look.18,24 During the follow-up of both irradiated and surgical patients with supraglottic SCC, we perform seriate videolaryngoscopies and diagnostic imaging as described earlier, and a microlaryngoscopy whenever a local relapse is suspected. In this way, we are becoming able to detect early recurrences and residuals for which salvage laser EHSL seems a valuable option, with acceptable functional results.
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