Early Vocal Fold Cancer Presents Delicate Choices

He said, though, that a five-by-five field size is pretty tight and that with a T1a lesion, edema wouldn’t be too much of a complication.

At this point, Dr. Mendenhall said, he would present the patient with options. Someone like this would be offered transoral laser resection or radiation therapy and given the choice.

This patient was treated with radiation therapy at 63 cGys in 28 fractions. Then his voice returned to normal. He seemed to have responded well to the therapy.

But 14 months later, he was back, reporting hoarseness again, as well as left ear pain and mild pain when swallowing. This time, the exam revealed a more invasive lesion covering two-thirds of the left cord and thicker in the anterior portion of the cord. There didn’t appear to be any cervical adenopathy and the motility of the cords was preserved.

This is not your run-of-the-mill, pushing-border type of squamous cell carcinoma, as Dr. Medina put it. It’s rather infiltrating.

What Is the Next Step?

Henry Hoffman, MD, Professor of Otolaryngology-Head and Neck Surgery at the University of Iowa in Iowa City, said he would try to get more information.

I’d probably get a CT on this patient, he said. I think it might be a little more extensive than you can see, especially in the face of failure of radiotherapy. This is one that, assuming that it shows it to be confined in a way that’s not eroding into the cartilage, doing an endoscopic resection would be best.

He said the pain in the ear and in swallowing was particularly concerning and was worried about the anterior commissure.

Dr. Medina said, though, that a CT scan didn’t reveal anything unusual.

Dr. Hoffman said his approach is to emphasize exposure of the lesion to get a better read on it then use an endoscopic procedure.

I also counsel the patient that there’s probably going to be more than one surgery in store for them because if we do expose the cartilage, which we may need to do to get down to the perichondrium, there are going to be some healing problems after our endoscopic resection.

He added, The counseling session is a bit prolonged, but I think it sets you up for the appropriate treatment under one anesthetic.

Dr. Medina asked about the difficulty of achieving negative margins with the endoscopic approach.