Annals of Otology, Rhinology & Laryngology 117(7)Suppl 199:1-24. © 2008 Annals Publishing Company. All rights reserved. Photoangiolytic Laser Treatment of Early Glottic Cancer: A New Management Strategy Steven M. Zeitels, MD; James A. Bums, MD; Gerardo Lopez-Guerra, MD; R. Rox Anderson, MD; Robert E. Hillman, PhD The 532 nm pulsed KTP (potassium titanyl phosphate) laser and the 585 nm pulsed dye laser (PDL) are photoangiolytic lasers that have been demonstrated to be effective for managing vocal fold dysplasia. The putative mechanism of action is selective photoangiolysis of the sublesional microcirculation. On the basis of this experience, early glottic cancers were treated by selectively targeting the intralesional and sublesional microvasculature. This approach was derived from Folk- man's concepts of neoplastic growth resulting from tumor angiogenesis. Staged microlaryngeal treatment was adopted, because it facilitated optimal functional results, and was considered safe, because early glottic cancer rarely metastasizes. Furthermore, intercurrent disease during conventional incremental radiotherapy is typical in treating early glottic can- cer. A pilot group of 22 patients with early glottic cancer (13 Tl , 9 T2) were treated with a fiber-based angiolytic laser. Eleven of the 22 had unilateral disease and were entirely treated by laser photoangiolysis as a sole modality. Eleven of the 22 had bilateral disease; 5 of the 11 were treated entirely (bilaterally) by laser photoangiolysis, and 6 of the 11 only underwent laser treatment of the less involved vocal fold, with conventional resection being done on the dominant side of the cancer. The initial 8 of the 22 were treated with the PDL, and the latter 14 of the 22 were treated with the pulsed KTP laser. No patient has cancer presently, and none have undergone posttreatment radiotherapy or open surgery. The mean follow-up is 27 months, 13 of the 22 patients have at least 2 years of follow-up, and the first patient was treated just over 5 years ago. Objective measures of vocal function revealed that photoangiolytic treatment of early glottic cancer resulted in significant postoperative improvements despite the fact that half of the patients had bilateral disease. Angiolytic lasers effectively involuted early glottic cancer, with microsurgically directed nonionizing radiation of the dense neoplastic blood supply resulting in complete tumor regression. This approach is conceptually attractive, because it is repeatable, it preserves all conventional cancer treatment options, and it results in excellent vocal function by improving phonatory mucosal wave vibration. Observations from this investigation suggest that this new and novel cancer treatment strategy is effective; however, larger patient cohorts, longer follow-up, and multi-institutional confirmation will be necessary to establish incontrovertible oncological efficacy. Key Words: glottis, laryngeal cancer, laser, microlaryngoscopy, phonomicrosurgery, phonosurgery, vocal cord, vocal fold, voice. INTRODUCTION Successful management of early glottic cancer re- quires that the clinician integrate a complex algo- rithm of interdependent host and tumor issues. The patient and surgeon must mutually consider the op- timal treatment method. This is based on efficacy of cure, potential detrimental effects of the interven- tions on normal tissue and voice quality, age and vo- cal needs of the patient, skill sets of the surgeon, pri- or oncological history of the patient, availability of technology, and repeatability of the treatment. These concepts were progressively established through the 20th century because of the increasing frequency of vocal fold cancer subsequent to the introduction of mass-produced cigarettes. The treatment of vocal fold neoplasms during the past 2 centuries comprises a rich history chronicling the development of minimally invasive endoscopic laryngeal surgery and radiation physics along with the development of our understanding of phonatory physiology in normal and diseased states. Indepen- dent and interdependent advances have led to cur- rent philosophies in which curative treatment is rou- tine, and optimal vocal outcome remains a pursuit. Because any adequate treatment for early glottic cancer (endoscopic excision, transcervical excision, From the Departments of Surgery (Zeitels, Bums, Lopez-Guerra, Hillman) and Dermatology (Anderson), Harvard Medical School, and the Center for Laryngeal Surgery and Voice Rehabilitation (Zeitels, Bums, Lopez-Guerra, Hillman) and the Wellman Laboratories of Photomedicine (Anderson), Massachusetts General Hospital, Boston, Massachusetts. This work was supported in part by the Eugene B. Casey Foundation and the Institute of Laryngology and Voice Restoration. The authors have not received commercial financial support, but have received laser instrumentation from KayPENTAX and Laserscope. Dr Zeitels has an equity interest in Endocraft LLC. Presented at the meeting of the American Broncho-Esophagological Association, Orlando, Florida, May 1-2,2008. Correspondence: Steven M. Zeitels, MD, Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, One Bowdoin Square, Boston, MA 02114. 3