Laryngeal Cancer: Clinical Case-Based Approaches

Review by PJ Bradley
Nottingham, UK

Laryngeal Cancer: Clinical Case-Based Approaches is a hardback book, offering punchy style chapter presentations, with clinical and surgical figures (exceeding 75 in number), radiology images (over 40), drawings, tables (more than 20) and one histology slide – the clarity and legends are an essential inclusion for such a format, as published by Thieme, 2019. The 4 Editors – Dedivitis (from Brazil), Peretti (Italy) Hanna (USA) and Cernea (Brazil) – have recruited 81 contributors from the Americas (North and South), Europe and Asia. Each contributing team has been challenged to present a case scenario in a structured format, comprising an abstract with key words, the case report (one with two reports) and discussion, followed by tips, tricks and references. There are over 600 references, of which over 50 per cent have been published since 2010. There were five references that were not completely cited but have since been published (which should have been updated at the time of proof setting), and one reference that seems not to have matured to publication!

The case-based approach, in my opinion, has worked. All of the contributing teams are to be congratulated, with most chapters comprising one to three authors, with, as always, two chapters with more than three authors.

Scenarios 1–6 discuss early glottic cancer treated surgically by laser surgery, robotic surgery and vertical hemi-laryngectomy. Scenarios 7–13, 16 and 17 discuss early and intermediate supraglottic cancer, occasionally straying back to the intermediate glottis, covering treatment by laser excision, horizontal supraglottic laryngectomy, vertical partial laryngectomy, supracricoid laryngectomy, radiotherapy and chemoradiotherapy.

Scenarios 14, 15, 18, 20, 21 and 23 discuss locally advanced glottic and supraglottic cancer treated surgically and non-surgically (organ preservation). Scenario 19 was of interest because of the surgical advances made by the Belgian team, and their ability to excise most of the cricoid cartilage, and yet rehabilitate the patient to a tracheostomy and gastrostomy-free survival. They explain the identification of suitable patients, the complexity of the surgery (in two stages) and the rehabilitation.

Scenario 22 discusses transoral robotic total laryngectomy; the authors reassure the reader that such an approach is safe, with minimal morbidity, resulting in a shortened hospital stay. Scenarios 24–27 discuss the use of salvage surgery after primary radiotherapy using the laser, supracricoid laryngectomy and total laryngectomy, and the strategy to minimise the risk of post-operative pharyngocutaneous fistula, by using a subcutaneous onlay vascularised muscle flap. Scenarios 28–31 describe and discuss the reconstructive methods employed to repair a pharyngeal defect using the pectoralis myocutaneous flap, supraclavicular island flap, latissimus dorsi myocutaneous flap and gastric pull-up.

Scenario 32 discusses the not infrequent dilemma of the ‘youngish’ adult who has an early primary tumour with advanced neck metastasis, and examines the use of single-course induction chemotherapy to assess tumour responsiveness, and the selection of a surgical or a non-surgical programme for curative intent. Scenario 33 discusses the trials ongoing in the application of systemic agents targeted against epidermal growth factor receptor, and programmed death 1 (PD-1) and programmed death ligand 1 (PD-L1) pathways. Much research is needed to identify suitable patients for the most appropriate drugs.

Scenario 34 discusses laryngeal transplantation (there have been only three comprehensive reports of single successful cases and so the traps presented need to be seriously considered), the risk of a solid and haematological malignancy in transplant patients, the financial cost, and the patient’s desire for improved quality of life after transplantation.

To quote a summary ‘of old’: ‘There are many choices of treatment for laryngeal cancer – but (currently) there is no treatment of choice’ (Javier Gavilan, 2nd World Congress on Laryngeal Cancer, Sydney, 1994).

This book, and its style of using the clinical case-based approaches, resurrects the debate on the educational benefit that can be derived from a well-structured case report. Six chapters do not follow the majority style and have presented a ‘textbook/historical’ text, usually too long and with too many references. The sequence of the case scenarios should have moved from early to advanced stage disease, as the tumour–node–metastasis (TNM) system does. The missing piece of the jigsaw was any comment on long-term function and survival. Most of the patients were male (male to female ratio of 25:3), and smokers or ex-smokers (n = 24), but I am surprised that some of the patients never drank alcohol! Little or no comment on this social habit and its risks was made, including the possible adverse effects of treatment, the surgical or oncological complications, and likelihood of second cancers.

It might have been helpful, maybe in the preface, to define the usage of the terminology used, including early, intermediate and locally advanced, presuming there is also widespread advanced laryngeal cancer. It seems that clinicians (surgeons and chemoradiation oncologists), need to rationalise the TNM system, which has stood the test of time for surgeons. However, our chemoradiation oncologists, by interpreting modern imaging, are able to estimate tumour and nodal disease volume, and these findings are able to predict disease responsiveness to non-surgical treatment and patient survival.

This book is a delight to read, good value, very comprehensive and detailed. It should be obligatory reading for all those involved in the management and care of patients diagnosed with laryngeal disorders, including surgical and non-surgical staff, radiologists, nurses, speech and language therapists, and others with an interest in advising and rehabilitating patients.

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