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BackTable / ENT / Podcast / Transcript #199
Podcast Transcript: Advances in Early Glottic Cancer Treatment Options
with Dr. Bharat Panuganti
Is a subtle voice change something to ignore? In this episode of the Backtable ENT podcast, hosts Gopi Shah and Dr. Ashley Agan speak with Dr. Bharat Panuganti, a laryngologist from Washington University in St. Louis, about the diagnosis, treatment, and management of early glottic cancer. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Introduction to Early Glottic Cancer: Symptoms & Risk Factors
(2) Evaluating Glottic Cancer: From Initial Voice Assessment to Advanced Intraoperative Imaging
(3) Vocal Fold Biopsies
(4) Surgery vs. Radiation Therapy for Early Glottic Cancer
(5) Common Challenges in Surgical Resection & Confocal Laser Ablation
(6) Maximizing Surgical Precision: Tools & Techniques
(7) Advanced Surgical Tools for Resection: Robotics & Infrared Technology
(8) Post-Op Care & Follow-Up
(9) Personalized Care & Decision Making in Early Glottic Cancer Treatment
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[Dr. Gopi Shah]
Hey everybody, welcome back to The Backtable ENT Podcast. My name is Gopi Shah, I'm a pediatric ENT, and I'm here with my lovely co-host and partner in crime, Dr. Ashley Agan, General ENT. How are you today, Ash?
[Dr. Ashley Agan]
Woo-hoo. I'm good, Gopi. I'm great. Always great when I'm across the mic from you.
[Dr. Gopi Shah]
I know. It's going to be exciting for this episode. Today we have Dr. Bharat Panuganti. He is a laryngologist practicing at Washington University in St. Louis, Missouri. Bharat is here to talk to us today about early glottic cancer care. Welcome to the show, Bharat. How are you?
[Dr. Bharat Panuganti]
Thank you so much for having me. I'm doing great.
[Dr. Ashley Agan]
Before we get started, tell us a little bit about yourself and your practice.
[Dr. Bharat Panuganti]
I guess I can go way back. I'm originally from California. I was born and raised and jumped around the country, went to St. Louis for undergrad med school, and then did my residency at the University of California in San Diego. Did fellowship with Steven Zeitels at the Massachusetts General Hospital. I practiced for two years at the University of Alabama in Birmingham and recently moved to Wash U in St. Louis. As a laryngologist, I do a full spectrum laryngeal surgery to be sure, but my main schtick, so to speak, is early laryngeal cancers and diagnosis, treatment, management thereof. It's probably about 50% of my practice.
[Dr. Gopi Shah]
How are patients finding you? By the time they've seen you, do they have their diagnosis or what does that look like?
[Dr. Bharat Panuganti]
It's usually a spectrum. As expected with early laryngeal cancer, primarily early vocal fold cancers, one of the primary presenting symptoms is dysphonia. Some people come to my clinic with the primary complaint of dysphonia as a referral from a primary care physician. I'd say that a large percentage of people that end up in a subspecialty practice in general and certainly in mine are referrals from ENTs and in those situations, generally speaking, they'll have gone to the operating room for a biopsy.
(1) Introduction to Early Glottic Cancer: Symptoms & Risk Factors
[Dr. Gopi Shah]
Just to go back, how do you define early glottic cancer? Is that just in situ or T1s?
[Dr. Bharat Panuganti]
That's a good question. Early glottic cancer, typically what that stipulates is stage 1 or stage 2 or T1 and T2 disease. That characterization is important. In general, early glottic cancers, if you look at the lymphatic supply or lymphatic drainage of the vocal folds, it's quite sparse, especially relative to the subglottis and supraglottis. Some of the basic features in early glottic cancer is it stipulates single modality treatment. That's either radiotherapy or surgery.
By virtue of what I just said, given that lymphatic drainage is sparse at the glottis, the next general way I would treat it. That is what defines an early glottic cancer. Mobility is at least partially preserved, which means that the underlying muscle of the vocal fold is at least partially preserved and you can get by with just using one treatment modality.
[Dr. Gopi Shah]
When these patients are presenting, the main symptom is going to be dysphonia, like you mentioned. Anything else that usually tips you off there that's more worrisome, like pain or trouble swallowing or anything else, or just some horses?
[Dr. Bharat Panuganti]
Generally for an early glottic cancer, dysphonia is the primary symptom. At the point where you start getting pain, what that generally implies is that there's deeper penetration of the tumor. That's a little bit more concerning. Someone's coming in and they have throat pain, it doesn't mean that it's more advanced than early glottic cancer, but it's strongly suggestive of the possibility.
Difficulty breathing, again, with an early glottic cancer, just by virtue of how early you're catching it, isn't usually something that you see. Other things like coughing up blood, sometimes you see that. Tumors in general, and certainly tumors that originate from the vocal folds are typically quite hypervascular. It's something that can occur.
[Dr. Gopi Shah]
This is typically squamous cell carcinoma?
[Dr. Bharat Panuganti]
Almost universally, and there are variants of squamous cell carcinoma that you see, papillary type squamous cell carcinoma, but for the sake of this discussion, I think for the sake of simplicity, it's almost universally a squamous cell carcinoma.
[Dr. Gopi Shah]
In terms of risk factors, I usually think of smokers. What other risk factors come into play and what demographics or who are the patients that you see that come in early with the early glottic cancer?
[Dr. Bharat Panuganti]
It's a really good question. I think head and neck cancer in general, and obviously the ZNTs were intimately familiar with the evolution in oropharynx cancer, the emergence, HPV being a primary etiology. I think there's been some evolution in early glottic cancer as well. This is unpublished data, but it's data that we submitted at the Academy Conference just last year. I, with my fellowship mentor, Steven Zeitels, we looked at all early glottic cancer patients that were either treated or diagnosed at the MGH Voice Center in Boston between 2002 and 2022.
Something like 27% of patients that came through the MGH Voice Center were non-smokers or never smokers. That is a very staunch departure from what we traditionally understand as the primary risk factor for laryngeal cancers, which is smoking. Overall, if you look at the population of people that develop voice box cancers, it's smoking. That's the major risk factor. If you look at some of the trends in laryngeal cancers in general, smoking incidence has gone down. By virtue of that, the incidence of larynx cancer has gone down. If you look at, I think in the last decade or so, the annual incidence has gone down on average by 3.5%.
[Dr. Gopi Shah]
You said almost 30% are non-smokers, would you say 27?
[Dr. Bharat Panuganti]
27, yes.
[Dr. Gopi Shah]
27. In that population, were there any trends or any risks that you could see? Were those people vaping or doing some other sort of tobacco or were they older or anything from that group? Because that's a pretty big chunk.
[Dr. Bharat Panuganti]
Oh yes. I should say that's probably not representative of the rest of the country. Boston, I would say just demographically and based on the population of people generally speaking that ended up at the MGH Voice Center, there's probably an over-representation of non-smokers relative to the rest of the population. That being said, amongst the rest of the factors that we looked at, there was nothing really outside of smoking. There's nothing we're meant to look for explicitly.
The only differentiating feature was that the average age among those non-smokers was a bit younger by about four years. Again, statistically speaking, it's significant, but objectively, it was a difference between 60 versus 64 years of age.
(2) Evaluating Glottic Cancer: From Initial Voice Assessment to Advanced Intraoperative Imaging
[Dr. Gopi Shah]
Interesting. In terms of your exam, can you take us through start to finish? Are you, as soon as they walk into the office, listening to voice quality, or is it all in the scope?
[Dr. Bharat Panuganti]
That's a really good question. I think, obviously you hear the dysphonia and that's something that suggests at least that a vocal fold pathology might exist. The diagnosis of a vocal fold cancer requires that you see obviously, and get a biopsy. Typically for a clinic encounter, someone comes in, if they hadn't been diagnosed before, we look at the larynx. Generally speaking, if I'm suspicious for a larynx cancer, what I'll like to do is use a flexible camera as opposed to a rigid scope through the mouth, both of which are totally viable options, generally speaking, for laryngeal examinations.
The reason I like flexible examinations is that you can really advance the scope, not just to the level of the vocal folds, but beyond it. It is important to understand the potential geographic footprint of a tumor because it does advise you, at least tentatively, about what the treatment options might entail. If there's a tumor that extends far into the subglottis, obviously that should change your preoperative thinking about whether or not this person might be a surgical candidate.
We take a look with the scope, get a feel for how extensive the tumor is. Then there are a couple of really important things that we look at, the first of which is, is the vocal fold moving? Like I mentioned before, whether or not the vocal fold moves is important for us to determine the clinical stage. If the vocal fold doesn't move at all, that is not an early laryngeal cancer. That automatically upstages to a stage 3 and a T3.
If there is some mobility at least, that is at least a T2, but that also goes into our consideration of what would surgery entail for this person. If there's limited movement to the vocal fold, that suggests that in order to clear the disease, you're going to have to resect a portion of the muscle. When we think about functional outcomes after surgery, and I'm sure we'll get into this a little bit later, but if we have to remove a big portion of the muscle, then that conveys directly to whether or not a person can get the vocal folds closed, which by virtue of that, I've get a person's voices and swallow is going to be after the surgery.
The other thing that we look at is the good side of the larynx. It is not uncommon for cancer to involve both sides, but in situations where one side is preserved, that can be quite meaningful because if you survey laryngeal surgeons-- voice is, in general, just an amazingly fascinating thing. One of the things that I think a lot of laryngeal surgeons will notice is as long as you have one good side that's vibrating, even if the other side doesn't vibrate, as long as you have a wall for the good side to vibrate against, you can have pretty darn good voice.
If you have a completely preserved side of the vocal fold that doesn't have to be operated on in terms of what the voice outcomes and the swallow outcomes might be, again, that portends potentially good outcomes. Those are the biggest things that we look for almost universally in my practice unless someone has just a really small, well-confined T1 vocal fold cancer, where there's basically no expectation after the surgery that they'll have any voice or swallowing problems.
They're all getting in-office swallow exams with a speech-language pathologist, so a functional endoscopic evaluation of their swallow, one, to make sure that their swallowing is intact preoperatively, but also to give us an idea of what they're able to do from a laryngeal perspective to overcome potentially, at least in the short-term, some issues with vocal fold competency. That's the basic clinic exam. This goes for anybody that's undergoing a surgery, full head and neck exam.
Primarily, what you're looking for is things that might suggest that laryngeal exposure intraoperatively might be difficult. Small jaw, presence of mandibular tori, poor neck extension, big tongue, anything that might make it difficult for you to align the scope from the point of the lips to the entrance of the larynx. Those are really important considerations because if you don't have the confidence you'll be able to expose the larynx, then you should reconsider whether or not an endoscopic transoral surgical approach to a larynx cancer is the best option for the patient.
[Dr. Gopi Shah]
Going back to your exam, just thinking about what the tumors look like, is there a very typical appearance as far as exophytic or sessile, and is it more commonly anterior commissure or can it be anywhere all over the place?
[Dr. Bharat Panuganti]
Yes, totally. No, they have different flavors, so to speak. Sometimes you're lucky and it's a nice exophytic tumor that's confined to one vocal fold. Those are the nice ones, especially if the vocal fold is mobile, because what it implies is that the pattern of growth is outwards and those are really easy to cut out while preserving the underlying vocal fold architecture. Sometimes it's all over the place and there's more sessile disease that expands from the front to the back on both sides.
Sometimes it's endophytic and the pattern of growth is into the vocal fold and in those situations it's easy to underestimate what the functional outcome might be postoperatively. I guess the basic lesson is to never assume what a cancer will look like based on a clinic exam and it's critically important that you get a good intraoperative exam and certainly a radiographic imaging as well.
[Dr. Gopi Shah]
Is a strobe ever helpful to you? Does that provide more information or does that change your management ever?
[Dr. Bharat Panuganti]
A stroboscopy is really important and it goes to what we were talking about before. You don't need a strobe to assess for basic vocal fold mobility. What a strobe gives you is what is the pliability of the vocal fold that's ipsilateral to the tumor. Say, for example, you have a tumor sitting on the vocal fold, you ask the patient to phonate and you see vibration of the mucosa adjacent to the tumor. What that implies is even if you remove the tumor, there's enough pliable mucosa adjacent to it that perhaps the voice outcomes will be good enough.
That is very important. If you see no vibration of the vocal fold, what that implies is that the postoperative functional outcome may not be as good as it could be if the former scenario was present.
[Dr. Gopi Shah]
Then what about using, is it blue light or narrow-band when you're doing your flexible scope to look at hypervascularity or-- Am I saying this right? Is that helpful?
[Dr. Bharat Panuganti]
Totally. Narrow-band imaging, I don't typically use it in the clinic setting, mostly because if I'm taking someone to the operating room, they're getting the whole spectrum of introvertive imaging anyways. I think one of the most difficult things about treating early vocal fold cancers is understanding the footprint. There's a lot that you can tell from the clinic exam, but there's a lot that you can't. You're restricted by the resolution of the camera from the clinic.
When you go to the operating room, you get someone exposed. I use the universal modular glottoscope system. I'm a little biased because I trained with the person that invented it. In my humble opinion, a really, really great scope and in my practice, mission critical for full exposure of the inside of the voice box. Get the vocal folds exposed, 8.7X surgical microscopic magnification to look at the surface of the vocal folds, you still sometimes can't tell what the footprint of the tumor is.
That's where a couple of additional imaging modalities that are a big part of my ongoing research, I think come in. You mentioned narrow-band imaging. Narrow-band imaging, basically what it does is it leverages two maximum wavelengths, bands that highlights the microvasculature. There are a couple of different diagnostic schemas that surgeons can use to classify lesions based on the microvascular pattern. Narrow-band imaging gives you a better sense of what is otherwise grossly visible, the microvasculature.
Engaging narrow-band imaging, sometimes you can see, "Oh, I see stippling here," which would suggest that maybe there's perpendicular angiogenesis that's causing a vocal fold lesion or allowing a vocal fold lesion to grow on the surface. Narrow-band imaging does potentially give you a better sense of the footprint of the tumor. However, narrow-band imaging, all it really does is allow you to see better what is otherwise grossly visible, which is these vessels that are either in the epithelium or below the epithelium.
If you really want to get into seeing what you can't see to truly understand what the footprint of a tumor might be, you got to get microscopic. 8.7x surgical microscopy isn't microscopic. If you want to be able to see cells and the subcellular morphology, you've got to go even deeper than that. Two of the things that I've been using are a couple of different intraoperative optical imaging modalities. One is called confocal laser endomicroscopy. It's a really neat tool that gives you 1000x magnification.
The system that I use is something called the Cellvizio system. It's based on differential fluorescein uptake. A patient gets fluorescein injected in the operating room intravenously. You put the probe on the surface of the tissue and you see individual cells. The probe has a field of view of 240 micrometers. What I do in the operating room before I even start doing the resection is I will map the entire surface of the inside of the larynx.
That includes, for early glottic cancer, both of the vestibular folds, the false folds, and both of the true vocal folds. I scan the surface. This is data that I haven't yet published, but what I'm finding-- and there's a whole set of criteria that we're adapting and now modifying to use for the diagnosis based on the cellular morphology of cancer versus dysplasia. What I'm finding is that even in situations where there's a unilateral tumor, I go to the contralateral vocal fold and I'm seeing foci of cellular aberrancies, which suggests that it is not uncommon for there to be cancer on one side, but at least changes on the other side that are suggestive of pre-malignancy that are usually not accounted for.
Then the other thing that we've been using, which is also part of this phase I clinical trial we're running, is something called Panitumumab Iodide 100. Panitumumab is an EGFR monoclonal antibody, and that's paired with a near-infrared dye. It's injected intravenously about 24 to 48 hours before the surgery. We use a special camera that allows for excitation in the near-infrared wavelength. We can see tumor volumes as small as 450 cells. This is a different thing that we can use, not just for surface mapping, but for the identification of disease deep to the surface.
Between the two things, my hope is that we would have created a paradigm from an imaging perspective where we can see both deep and surface disease in a way that we haven't been able to before.
[Dr. Gopi Shah]
The fluorescein, when you inject the fluorescein for the confocal laser, is that through the IV or is it topical on the tumor?
[Dr. Bharat Panuganti]
It's intravenous and then obviously vascular. Within about seven seconds, I'll see the fluorescein light up in the larynx. It's pretty remarkable.
(3) Vocal Fold Biopsies
[Dr. Gopi Shah]
Then if you have like a foci of aberrancy, do you send that for frozen? Do you get intrapathology frozen, "Hey, this could be something before I start doing anything on a side that I wasn't expecting, maybe?"
[Dr. Bharat Panuganti]
Yes, totally. The problem with early vocal fold cancers and the impetus for this entire avenue of research is that if you look at the vocal fold, in terms of what you see exposed generally when you do a flexible laryngoscopy, which I think most ENTs will do that are looking at larynges, in an adult, the visible portion of the vocal fold is about four millimeters in width. The full width of the vocal fold is longer, but just in terms of what upfront.
The superficial lamina propria, which is the critical layer of the vocal fold that's responsible for vibration, is between 50 to 150 micrometers. If what you're trying to do is maximize postoperative voice function, you can't take big honking biopsies. By the time you take a biopsy, you send it off for a frozen section and they go through the process of preparing the frozen section for analysis. The cautery artifact that's introduced makes it really difficult to accurately diagnose based on small-volume frozen section biopsies.
My practice has evolved to some degree. For the sake of preoperative diagnosis, I typically don't do frozens and that is in large part because of what we just talked about, that it's hard to rely on histopath explicitly when we're sending these tiny, tiny biopsies, but also because if it is truly just surface occult disease, with the way that I treat vocal fold cancers, you can treat it with basically no functional sequelae as a result of it. My practice is I'll take frozen sections for margins at the end of the case, but I won't take it upfront.
[Dr. Gopi Shah]
I think that's a really good point regarding biopsies. For your referring doctors who are sending you patients, are they typically not biopsying them and just saying, "This looks like it's something bad," just because it's small, and if they biopsy it might be gone and you may not be able to see it once they get to you? What's that process so we back up a little bit?
[Dr. Bharat Panuganti]
Absolutely. That's a really good point. I think that to get a diagnosis before referring someone, absolutely. Totally appropriate. I do think that there's some risk with exactly what you just said, that if it is a small lesion and you don't take a deliberate biopsy where you're respecting the micro-layered underlying architecture of the vocal fold, that there's some risk, one, that the biopsy cures the cancer, at least clinically, where it becomes really difficult for the person that's getting referred the patient to understand exactly what they're meant to clear.
Two, the other problem is the biopsy itself could destroy the voice. I think in a situation where there's any apprehension about what a biopsy would do, in my practice, especially, I don't stage the biopsy and treatment. It's all one stage anyhow. In my hands, I'll do the biopsy and treat everything up front. There's really no risk to holding off on the biopsy, simply saying that a lesion is concerning enough that you think it might be cancer and just shuffling off to referral if the intention, of course, is not to treat it eventually.
[Dr. Gopi Shah]
Bharat, just so I'm clear, you have a patient that comes to clinic, you're not immediately biopsying then. Maybe you'll get a CT neck or whatever for further workup and then plan for the path and if there is a treatment to be done all at the same time. Your case posting could be as quick as 45 minutes to a couple of hours.
[Dr. Bharat Panuganti]
Yes. I don't typically take in-office biopsies and there's nothing wrong with it since I'm biopsying and treating in one stage. To me, it doesn't actually save any time or the patient a trip to the operating room for the sake of a biopsy. My personal practice pattern is not to do that. In terms of a posting, typically what I'll call it is a suspension microlaryngoscopy with biopsy, possible laser-assisted resection of a tumor.
If it's apparent intraoperatively that surgery is not appropriate, then the case could last about 15 minutes. I will always, in the operating room, not just look at the larynx, but I'll look below as well. I'll do a diagnostic tracheobronchoscopy just to look for occult endobronchial disease. You mentioned this before, but CT imaging, I think there's a misconception about whether or not chest imaging is necessary for early vocal fold cancers. I always get chest imaging, not because I'm worried about metastasis, I get chest imaging because I'm worried about a second primary. All my patients, regardless of how small the vocal fold cancer is, will get CT neck and chest imaging.
[Dr. Gopi Shah]
Typically these early glottic cancers can be invisible or really hard to see on a CT. Right?
[Dr. Bharat Panuganti]
That's right. Yes. Even big ones can be hard to differentiate because it's hard to differentiate a tumor sitting on the surface of the vocal folds from the underlying mucosa, and you never know what the position of the vocal folds are going to be. Sometimes the patient is voicing or coughing at the time that that shot is taken and they're abducted, in which case it's impossible to differentiate a mass from just the structure of the vocal folds themselves.
Generally speaking, CT imaging is not terribly good for imaging, especially surface vocal fold cancers. It's really just a mechanism to make sure that there's nothing else worrisome in the larynx or the neck.
[Dr. Gopi Shah]
Also, if the read comes back that it's normal and negative, it's also not reassuring because you need to correlate it with direct visualization.
[Dr. Bharat Panuganti]
That's right. Exactly.
[Dr. Ashley Agan]
The standard line.
[Dr. Bharat Panuganti]
Exactly.
[Dr. Gopi Shah]
When you're taking a look in the office, it sounds like if it's obvious, maybe it's obvious, but what's on your differential? What other things are you thinking about and what else should we be considering?
[Dr. Bharat Panuganti]
If someone just has a lot of, I just call it schmutz, smoker, maybe a history of larynx cancer before, previously radiated, someone that is on a steroid inhaler, fungal infection, that's a big thing. Sometimes really bad fungal infections can masquerade as what appears to be a tumor in the clinic. If there's any doubt, I will put someone on an antifungal medication, an oral Diflucan typically just to see if there's interval resolution. Now those two things aren't mutually exclusive either.
You can have a fungal infection and cancer. Something to consider. If there's any doubt in my mind about whether or not there's a fungal infection, I'll treat them presumptively, and either say, "Why don't we just meet in the operating room for me to take a look after or just come to the clinic so we can get an interval exam." Sometimes something looks bad, but it's not cancer and it's dysplasia. There are different vocal fold lesions, again, besides cancer that can masquerade as a mass lesion.
You can have dysplasia, you can have parakeratosis, you can have hyperkeratosis. Obviously what they stipulate is that there is invasion beyond the basement membrane.
[Dr. Gopi Shah]
In just thinking of patients that are coming through your clinic and how that process is flowing, once you're concerned at all and you know, "Okay, we need to biopsy this," how do you talk to patients about that? It sounds like most of the time, whether it's cancer or not, it's going to be a diagnostic and therapeutic type of intervention.
[Dr. Bharat Panuganti]
That's exactly right. If it's something that's on the vocal fold that is impairing the voice that's not infectious, then it's got to go one way or the other. Typically what I'll tell a patient is in the operating room, my microscopic exam is good enough where generally speaking, I'll have a good sense of whether or not what we're dealing with is cancer. That's also where the other imaging modalities come in with a confocal laser and a microscopy.
Of course, if there's a mass lesion that isn't just a surface lesion, we can send it off for the frozen section. We can take a big chunk and get help from the pathologist and drop. The conversation generally is go to the operating room, take a biopsy. If there's concern for cancer, if there's concern for something that shouldn't be there, a mass, lesion, hyperkeratosis, perikeratosis, dysplasia, the approach is fundamentally the same, which is to use a laser to remove the lesion.
(4) Surgery vs. Radiation Therapy for Early Glottic Cancer
[Dr. Gopi Shah]
Got you. Are you even talking about other treatment modalities at that point? We think about the early T1 cancers being also treatable with primary XRT, but we don't know it's cancer yet. How do you talk to patients about that?
[Dr. Bharat Panuganti]
If we don't have a cancer diagnosis, and if there's any doubt in my mind about whether or not moving forward with surgical treatment is the best option for the patient, then the conversation is always, let's first get a diagnosis. Let me take a look around, get a sense for the depth of the mass. If my impression in the operating room is that it's at least worth a conversation about whether or not primary radiotherapy is a better alternative, then that's what I'll do.
I'll stop the surgery, wake the patient up, and have them come to the clinic to have that discussion. A lot of the time, someone comes in with a diagnosis, which is nice because in that situation, we can have that entire conversation upfront. I historically have had very, very good relationships with the radiation oncologists. At UAB, what I would do is if a patient came in and there is a conversation to be had about whether or not radiation versus surgery is the better option for them, then I actually just call the radiation oncologist and they come to the clinic and we all have a conversation together.
It's really nice to compartmentalize everything, make it really nice and simple for us to be able to have a multidisciplinary conference in a clinic encounter to chat about risks, benefits, pros, cons of either approach.
[Dr. Gopi Shah]
How do you start organizing it in your mind of, "This is going to be a great surgical candidate," or "Hey, XRT is going to be better?" It sounds like you already have that in your mind.
[Dr. Bharat Panuganti]
Totally. That's a really good question. I think some of it is idiosyncratic. My perspective is probably a little bit different than another laryngologist, but I guess speaking from my own experience, the way that I think about it is I try to boil it down and make it really simple. One big thing, can I see the tumor? If someone has had multiple neck fusions and there's no opportunity for me to stick a scope in and say reliably that I have been able to expose the entirety of the larynx, then I couldn't possibly convey to the patient with any degree of confidence that I've cleared microscopic disease.
That's a really easy situation for me upfront. If someone's just not a good surgical candidate based on head and neck anatomy, that conversation about radiation treatment is had upfront. Beyond that, really the simple question is, do you think you can clear disease? It sounds like a stupid thing to say, but to really simplify it that way, I think makes the decision-making process a little bit easier.
The considerations there, is this a really sessile tumor? Not a big tumor, but a sessile tumor, a carpet of tumor that extends between or among different parts of the larynx. A stage 2 cancer can simply mean that the vocal fold can be mobile, but if there's cancer on the epiglottis, the vestibular fold, the glottis, and the subglottis, that's a really hard thing to clear surgically. It's just a larger footprint and the bigger it is, the harder it is to make certain that you've cleared margins.
Those are typically situations where I will have a conversation upfront about radiation therapy. If a tumor is really big and there's clearly impaired vocal fold mobility, again, that's another situation which I will have a conversation about radiotherapy. Now none of these are absolutes. There are situations where big tumor, vocal fold doesn't move that much, but it's just because the tumor is big and by the time you remove it, vocal fold is moving better.
A lot of the conversation is had before the surgery, but in situations where there's any doubt for me, I will tell the patient that in my belief that if we go to the operating room, I start to resect the tumor, and if I believe that to finish the resection would result in a prohibitive functional defect that would potentially be avoided with radiation therapy, then I'll stop and wake them up before any damage has been done, so to speak, because by the time you start carving into the vocal fold, whether or not you have radiation, that vocal fold's gone.
It's important to make that determination upfront, but that is a conversation I will very explicitly have with the patient is, "You have to trust me, and if I believe that it's not appropriate, then I'll stop."
[Dr. Gopi Shah]
Are there any other treatment modalities that are talked about? Is there a role for chemotherapy or immunotherapies or anything else happening from a treatment standpoint?
[Dr. Bharat Panuganti]
For early glottic cancer, no. Typically it's surgery versus radiation. Surgery has undergone evolution over the course of time. Now it's primarily transoral laser microsurgery, but ultimately, however you drop the laser in, whether it's with a robot or a microscope and an endoscope, it's primarily laser surgery.
[Dr. Gopi Shah]
Is the radiation therapy pretty much the same as it's been, or is it more focused or, as far as-- As ENTs, I think we all have that cringe with radiation because we've seen patients that have had really bad swallowing outcomes or problems with complications. Is that better?
[Dr. Bharat Panuganti]
It is. I think radiation therapy has undergone really significant evolution over the course of-- I can't give you a timeline, but certainly, in contemporary times, people have studied single vocal fold irradiation with IMRT. You can really restrict the radiation dose to the target organ, and as much as radiation oncologists have been able to historically, restrict the dose to the constrictor muscles and pharynx and carotids and all the things that we worry about in terms of postoperative radiation sequelae, they're not gone, but I think certainly compared to what it has been historically, have been mitigated to a significant degree.
That being said, I think with radiation, it's not as simple as the physics. Different patients will have different outcomes. It's a hard thing to predict. Some people don't respond well to radiation. Some people go through radiation and it's as if nothing ever happened. If it was an easier thing to predict, I think this conversation around what is a more appropriate treatment per patient would be a lot simpler. I think in general, the functional deficits associated with surgery are a little bit more predictable because you are directly responsible for the defect that you create.
In terms of functional rehabilitation, there are options for surgery. If primarily the problem that you have is a soft tissue deficit, there are things that we can do to overcome that, that injection laryngoplasty being my favorite option to restore some of that lost soft tissue bulk in a way that can restore glottic competency. Once you do that, especially if you have a good contralateral side, there's an opportunity for a really, really nice postoperative functional outcome.
[Dr. Gopi Shah]
That's really where the decision-making-- that's what it's about. The cure rate for an early T1, these patients are going to be cured of their cancer. It's just, what's their laryngeal function going to be afterwards.
[Dr. Bharat Panuganti]
Conversations about this, where there's true survival equipoise between two treatment modalities, it's fascinating because there's a lot of considerations. It's not just about the surgeon. It's not just about the radiation oncologist, it's about the patient. With surgery, for example, I always tell patients that they may need laser treatments in the clinic. The way that I treat cancers is with the KTP laser. It's ultra-narrow margin surgery.
I'm not chunking out a large portion of the vocal fold because these aren't cancers generally speaking that are going to kill patients. We have license as surgeons to be a little bit more conservative. This has been proven a number of times in the data. This isn't just a theoretical talk where ultra-narrow margin and narrow margin surgery is appropriate for early vocal fold cancers because the implications of recurrence are not the same as if it was in the tongue, for example, or the oropharynx where you're worried about local or regional and distant metastasis.
(5) Common Challenges in Surgical Resection & Confocal Laser Ablation
[Dr. Gopi Shah]
When you say narrow or ultra-narrow margins, how many millimeters or micromillimeters are we talking about?
[Dr. Bharat Panuganti]
That's a good question. There are basically two methods to treat early vocal fold cancers. One is to cut the cancer out and one is to ablate it. If you look at the laryngeal surgeons and the TLM surgeons, transoral laser microsurgery surgeons that do early vocal fold cancers, generally speaking, they'll use one of two different kinds of lasers, the CO2 laser or the KTP laser. The CO2 laser is a non-selective laser. A cutting laser. Basically what it does is its chromophores water.
You use it to cut tumors out. With the ablative laser, the KTP laser, I'm not actually cutting a tumor out and sending a specimen to a pathologist. What I'm doing is ablating the tumor, vaporizing it, and then treating the bed with the laser itself. The margin is not exactly quantified in that situation. A lot of it is based on what the tissue looks like at its base. It's hard for me to say exactly what an adequate margin is. I don't think that there's an answer for that because it's a really hard thing to characterize.
By the time you take the cancer out, the tissue artifact and in a lot of circumstances, even with the CO2 laser, you do what are called piecemeal resection. You're cutting portions of the tumor out so that you can see the vocal fold a little bit better before you perform the rest of the resection. By the time the specimen comes out, there isn't the kind of specimen orientation with those discrete quantifiable margins that you'll see in other parts of the head and neck. That's what makes this challenging.
If you look at some of the data, early vocal fold cancer resections with TLM have a 20% positive margin rate. That is asinine. I think that if you were to propose that or present that data to any other cancer surgeon, they'd say, "That's absolutely ridiculous." It's a function of what I think we're forced to do when we do transoral laser microsurgery is, one, with the piecemeal resections, I think it's hard to truly characterize positive margin rate, but two, if you truly want to clear presumptive margins, you're knocking out a big portion of the vocal fold and that can have bad outcomes. You don't have to do that for a patient to survive. That's where it gets a little complicated.
[Dr. Gopi Shah]
There's a lot of reliance on what the tissue looks like and being able to recognize if something looks suspicious or not.
[Dr. Bharat Panuganti]
Absolutely.
[Dr. Gopi Shah]
With the confocal laser, are you going back with that after you've done your ablation to look again?
[Dr. Bharat Panuganti]
Yes. Sometimes I'll do that. Sometimes I'll just use it up front and just map the tumor out and then resect the tumor accordingly. Sometimes I'll have doubts and I'll put the probe on at the end and I'll assess the peripheral mucosal margin status. That is a really, really nice tool that overcomes some of the limitations of small-volume histopathology.
[Dr. Gopi Shah]
Does that probe have a way to mark the tissue as you're using it?
[Dr. Bharat Panuganti]
That's a really good question. It's something that I'm actively working on. There isn't. A lot of it is based on extrapolation. I have everything recorded so I'll go back in the recording and see precisely where the probe is relative to where I'm meant to take biopsies or carve out the tumor from. It would be nice if there was something projected in real-time.
[Dr. Gopi Shah]
Yes. If you could have a little tattoo where you were stenciling out your area.
[Dr. Bharat Panuganti]
That's right.
[Dr. Gopi Shah]
That's cool. More to come then on that.
[Dr. Bharat Panuganti] More to come. We're looking at a digital projection. Something that in real-time we can-- instead of a tattoo that's physically on the tissue, something that is digitally projected so that there's no artifact on the organ itself, but you have the ability to extrapolate what you've seen with the CLE, with what you're seeing through a microscope
(6) Maximizing Surgical Precision: Tools & Techniques
[Dr. Gopi Shah]
It's an overlay like on what you're seeing in real-time. That's nice. As far as just thinking about, as you're in the operating room, other considerations, you talked about exposure, you talked about your scope of preference. Just talk to us about your setup and what's on your back table. What are the key things when you're doing this?
[Dr. Bharat Panuganti]
I think it's worth talking about the scope a little bit. If you think about the way that I'd say most ENTs in the country expose the larynx, they use a fulcrum secure like a Dedo, for example, stick the Dedo in, you put something in at the end or you have something grab the C portion of the handle and then you crank it against a table. That's tried and true. What it does is it's cantilevering against the maxilla.
You're not really maximizing exposure because the maxilla is fixed to the head. It's fixed to the cranio-maxillofacial skeleton. What I use with the universal modular glottoscope system, it pulls up against the jaw. It's true suspension, so to speak. It, instead of cranking against the maxilla, pulls up against the jaw. You're getting true anterior excursion of the scope against the larynx. What else is on the table? Micro instruments for the biopsies. KTP laser is not being serviced anymore, but it is what most laryngeal surgeons that do ablative work will use. That's the major surgical tool of mine.
[Dr. Gopi Shah]
When you say it's not being serviced anymore, what do you--
[Dr. Bharat Panuganti]
Boston Scientific bought it and shuttered it.
[Dr. Gopi Shah]
Oh, I didn't know that.
[Dr. Bharat Panuganti]
There's no new KTP being manufactured and Boston Scientific doesn't service the machines. You'll have to go to a third party. It doesn't mean that if a KTP machine has problems that you can't use it, but it becomes a lot more difficult. Once all the existing KTP machines die out, they will be no longer.
[Dr. Gopi Shah]
I didn't know that.
[Dr. Bharat Panuganti]
Yes. There are a couple others on the market that furnish blue light lasers. A diode blue light laser. That is the next generation of ablative laser use. For the time being, I'm a green-light believer. That's what I use. Then we'll have a series of micro-instruments, cups, right-left scissors, right-left, tiny one-millimeter, two-millimeter instruments so that I can take small-volume biopsies.
[Dr. Gopi Shah]
You do always send at least a small biopsy so that you can have a sense of whether this is dysplasia or cancer before you start ablating.
[Dr. Bharat Panuganti]
I will take numerous biopsies actually. What I mentioned with the tumor mapping with the confocal laser and microscopy is in any area where there's potential concern, if it's clinically normal, but evidence of potential aberrancy on CLE, I will take a biopsy there and send it off. Again, that's difficult because with the size of the biopsies that I'm taking, especially in a clinically normal area, I don't like to rely on frozen sections, so I send them for permanent pathology. On average, I'll take about five or six biopsies upfront.
[Dr. Gopi Shah]
These are little bitty biopsies.
[Dr. Bharat Panuganti]
Little bitty biopsies. Yes. Really tiny biopsies.
[Dr. Gopi Shah]
Are they like, "You don't have enough tissue. Send us more?" You know how they like to do.
[Dr. Bharat Panuganti]
Oh, tissue loss to processing is something I see in pathology reports all the time. It dissolved in the saline before it got to the lab. We do that. One of the things that I really like to do is a sub-epithelial saline infusion. I'll have this injection cannula and I use injectable saline, so preservative-free saline, and I put the needle in the sub-epithelial layer. This is something that a lot of people do, but certainly something that my fellowship mentor Steven Zeitels was very specific about conveying the importance of.
Put it directly into the sub-epithelial layer into the superficial lamina propria. What you're looking for in the course of injecting before you do any of the surgery is do you see the mass lift up? If it lifts up, what it implies is that there's some of the superficial lamina propria intact and that the mass isn't all the way through the superficial lamina propria into the underlying ligament. I do that also to create a heat sink. In the course of doing the laser ablation, the superficial lamina propria, that's sacred ground.
Anything that you can do to preserve it within the confines of what's oncologically appropriate, mitigating thermal collateral injury by infusing the saline can be potentially helpful. That's pretty much it on the back table micro-instruments. The KTP laser fiber that I use depends on the size of the mass. If it's really a sessile disease just on the surface, I'll use a small one, so 400 micrometers. If it's a bigger one, then I'll use 600 micrometers and it makes a big difference.
It doesn't sound like a lot, but it makes a big difference during the surgery. Laser is conveyed in one of two modes, either pulsed or continuous wave. Pulsed wave and there are different ways to titrate the settings, but I'm not going to get into the nuances, but basically, it shoots a little blast of the laser. Continuous wave is exactly that quasi-continuous where there isn't the break in between pulses. I'll use continuous wave in situations where there's a big exophytic tumor that I'm trying to debulk.
[Dr. Gopi Shah]
The KTP is on a handpiece or mounted to your scope?
[Dr. Bharat Panuganti]
KTP is on a handpiece. The CO2, you can do obviously connected to the scope and control with a micromanipulator.
[Dr. Gopi Shah]
Are you ever using the CO2?
[Dr. Bharat Panuganti]
In my practice, I don't.
[Dr. Gopi Shah]
When the KTP can't get serviced.
[Dr. Bharat Panuganti]
Yes, exactly.
[Dr. Gopi Shah]
It's that or the diode?
[Dr. Bharat Panuganti]
Yes, when the KTP is no longer available for my use, which will be a very, very sad day, I'm going to use the blue light.
(7) Advanced Surgical Tools for Resection: Robotics & Infrared Technology
[Dr. Gopi Shah]
Bharat, when we were talking about doing this episode before, you mentioned robots as well, robotic surgery. Tell us a little bit about what that gives you or when you would consider using that as a tool.
[Dr. Bharat Panuganti]
I think for early glottic cancers, at least in my view, there's not really value for the robot. I think about the robot primarily for supraglottic tumors. What the robot gives you is a global view. If you think about the way that you expose a larynx with a tubular endoscope, no matter what it is, you are restricted to the confines of the tubular endoscope. You are excluding everything outside of it. For a small tumor, fine, it doesn't matter.
For a bigger tumor, if you can't see the entire tumor within the confines of the tubular endoscope, then you're having to maneuver the scope repeatedly in order to maximize your view or to see the entire footprint of the tumor. I think any situation in which you're having to do that risks traumatizing mucosa, risks traumatizing tumor, makes it really hard to differentiate between the two, makes it more likely that you miss stuff.
I had one of the robotic reps actually, before I started using the robot, come to my operating room and she counted the number of times I either moved my microscope or moved my laryngoscope in the course of the three-hour case. It was 100. That to me, was wild. I do it subconsciously, but it's really representative of how hard it is sometimes to see the inside of the larynx globally. I think the incremental value of the robotic exposure is to be able to manipulate the semi-flexible endoscope in a way that doesn't require repositioning of the scope itself.
The other possible advantage is based on what we were mentioning before, which is confocal laser and a microscopy. With the Cellvizio system, you can directly implement the imaging from the CLE, the confocal laser microscopy into the surgeon console view. I can drop the probe through the mouth, scan, put the probe down, pick up the laser adjacent to it, and start going. You can't do that with an endoscope because the way that I look with the probe is with a flexible bronchoscope so I can get all the angles.
I can't control it with a rigid scope. I have to put the bronchoscope in, take the microscope out, look, put the microscope back in, and hope that I'm ablating the right area. With the robot, because everything is integrated, it becomes a lot easier for you to integrate the information that you're getting with CLE in the course of doing the resection. Those are two of the major advantages. I think in terms of early laryngeal cancers, the benefit really at this point is restricted to supraglottic cancers, mostly because you get a better view. Hopefully in due time with the miniaturization of some of the instruments and the scopes, it'll be easier for us to use robotic instrumentation for vocal fold work.
[Dr. Gopi Shah]
You talked about with KTP, you're ablating, vaporizing the tumor. PPE for you, do you wear an N95 mask because of that?
[Dr. Bharat Panuganti]
Yes, it's a good question. I do for papilloma, so HPV disease, but for anything else, I just wear a regular mask.
[Dr. Gopi Shah]
Is there a suction cup to your scope that's evacuating those tumor vapors, I guess?
[Dr. Bharat Panuganti]
Yes, there's a suction connected to the scope and I'll have a suction adjacent to my laser too. Double power.
[Dr. Gopi Shah]
You had mentioned before about the infrared wavelength technology to help you measure depth. Do you use that at the end of the case to check, "Did I get deep enough?" When does that technology come into play or is that something that's new and upcoming?
[Dr. Bharat Panuganti]
That is only being done right now within the confines of a phase I clinical trial that we have ongoing. That is done basically throughout the case. I've only actually done it four times now. The purpose of it is not necessarily to measure the depth, but to understand if there's tumor left on the deep surface. That's being deployed. All that is is a special camera that can excite in the near-infrared wavelength. You can put that in basically whenever during the course of the resection to see if there's disease left.
It's a nice tool because it doesn't require that I change anything. You can actually ablate with the rigid endoscope to boot. It's a really nice handy tool. There are some problems with visualization at the level of the vocal folds that are probably beyond the scope of this conversation, but something that we're hoping to release to the wild soon.
(8) Post-Op Care & Follow-Up
[Dr. Gopi Shah]
As you're concluding the case, you've ablated the tumor, you're inspecting visually and you feel like, "Okay, this looks like ultra-narrow margins have been achieved, we're done," and as far as post-op considerations, what do you talk to your patients about what to expect? I assume they're not needing a tracheostomy because again, we're talking about early T1 small tumors.
[Dr. Bharat Panuganti]
Yes, you're right. Trachs, basically never. Really the biggest considerations post-op, the larynx usually doesn't hurt. What hurts is floor of the mouth on the right side. I always go on the right side. Scope is situated between the mandible and the side of the tongue. Not uncommon to have micro tears at the glossitantular junction. Some people will have numbness, just a neuropraxia from the scope being situated next to where the lingual nerve goes to the tongue.
Some people have a taste change for a couple of months. It's almost universally temporary, but the biggest problem that people complain about is throat pain just from the exposure, but that's the cost, unfortunately, of getting a better view.
[Dr. Gopi Shah]
Do they need to be on voice rest or have a special diet or are they just back to normal?
[Dr. Bharat Panuganti]
Diet is based on the extent of the resection. If there's any concern about having resected muscle enough where there's glottic incompetency, I will always keep those patients for a post-op day one inpatient swallow evaluation before sending them home. If it is truly a superficial resection, they go home the same day. Swallow protocol depends on extent. In terms of voice rest, I've evolved a little bit over the course of time. I used to be very adamant about keeping people on voice rest.
This isn't based in data, frankly, but what I realized is that in situations where-- If it's a de-epithelialization of the entire vocal fold, I haven't anecdotally noticed a big difference between someone being on voice rest for a few days, not being on voice rest at all. I think generally speaking, if someone's hoarse, they don't like to talk. It doesn't really make a big deal in my mind. Again, that's not a universality, but I'm generally a little bit less of a stickler when it comes to voice rest after a vocal fold tumor resection.
On the flip side, if someone has a nodule surgery or a phonomicrosurgical surgery, and I'm worried about a flap sitting, to maximize voice outcome, I am absolutely sure that they need voice rest 100% of the time.
[Dr. Gopi Shah]
Then in terms of overall survival, how do you counsel patients? How do you survey them? What is the follow-up after that?
[Dr. Bharat Panuganti]
Survival, excellent. Large population data, T2s, 80%, 85%, 90%, depending upon the study. T1s, a lot higher, 90% to 95%. I generally tell people that obviously, this is curable. I think a big part of making sure that early glottic cancer, even if it reccurs, stays early glottic cancer is surveillance. It's a big part and that's universal of course across the head and neck. I just follow the standard NCCN guidelines. The first year every two months, second year every two to four, third year every four to six, then six to eight, then every month or every year after five years.
[Dr. Gopi Shah]
Are you just doing flex scopes or do you strobe or what's your routine?
[Dr. Bharat Panuganti]
That's really just a function-- I think if there is a subtle lesion, if you notice a perturbation and vibration, it's something that can give you a hint that something exists. The other thing that I'll do is in situations where some people are just prone to redeveloping keratosis and we don't know if it's cancer or dysplasia or anything truly concerning because we're not taking biopsies, but that's the value of seeing them in clinic with a flexible scope is if we see something, history of early glottic cancer, just throw a laser in and ablate it presumptively.
It's a five-minute procedure, get them numb, no general anesthesia, and they go home about 10 minutes later. It's a really nice way for us to be able to manage disease, again, in a way that doesn't require that we whack a big part of the vocal fold and maintain treatment in a way that doesn't require that they go to the operating room.
[Dr. Gopi Shah]
Are there any features on pathology after the surgery that are red flags or that change your management at all?
[Dr. Bharat Panuganti]
I don't know if there are any features on pathology itself that would change my management. I think that if a cancer is poorly differentiated, generally speaking, in my mind, that's a bad sign and suggests perhaps that a conservation endoscopic approach may not be in their best interest. For the most part, pathology is usually confirmatory and simply corroborates what I basically know in the operating room anyhow.
[Dr. Gopi Shah]
With 20% positive margins, do you expect that as you're surveilling these patients, they're going to need that office ablation more commonly compared to other types of cancers in the head and neck?
[Dr. Bharat Panuganti]
If I get a positive margin, we're going back to the operating room 100% of the time. If I get a positive margin again, radiation. That's just my protocol because if I can't clear disease surgically after two bouts, that's an explicit sign that surgical management is not appropriate, in my mind, at least. If someone has a positive margin and we clear it the second time, I don't think that really affects whether or not they will need more in-office management. I think it's more than likely just a simple function of underappreciating disease that existed initially.
[Dr. Gopi Shah]
When you're counseling patients pre-op and talking to them about, "Okay, you're going to need to see me regularly. We're going to have to take a look and you may need to get this other procedure," how often would they potentially need to have the office ablation or does it just depend? Is there an average or not really?
[Dr. Bharat Panuganti]
I don't know that I have that information for you. I think most people don't. Some people do.
[Dr. Gopi Shah]
It's not a common thing?
[Dr. Bharat Panuganti]
It's relatively common, but I think that the majority of people that undergo a TLM approach don't usually need something regularly in the office.
[Dr. Gopi Shah]
Got it. It's not something that they need to expect to have to be done, but it's a possibility.
[Dr. Bharat Panuganti]
That's right. Absolutely.
[Dr. Gopi Shah]
In terms of equitable care, what are some of the challenges you've seen? We're talking about early glottic cancer care. Those patients who are able to see you while it's early, realizing that they have glottic cancer, they're red flags that maybe present quicker. What do you see in terms of providing equitable care or challenges to gaining--
[Dr. Bharat Panuganti]
I think in general, radiation is by far the most common treatment offered for early glottic cancer. I think part of that is just availability. The vast majority of the country geographically, there isn't someone that's doing TLM surgery. Just by virtue of what radiation is, it's simply more available. I think generally speaking, in terms of equity, I think that the average person is much more likely to have radiation as an option versus TLM.
Beyond the simple availability of laryngeal surgeons doing this kind of surgery across the country, I can't tell you exactly what the link between insurance coverage and access to care is, frankly. We did publish a study a few years ago, looking at rates of surgery versus radiation for early glottic cancer care after Medicaid expansion with the PPACA. We did find that among states that expanded access to Medicaid, there was a significant increase in the proportion of patient time versus time that we're getting surgery versus radiation for early glottic cancer.
How do we explain that exactly? It's tough for me to say, but I do believe that access to TLM is a problem, just like access to surgery across the spectrum of head and neck cancer care is also potentially problematic.
(9) Personalized Care & Decision Making in Early Glottic Cancer Treatment
[Dr. Gopi Shah]
Do we know, as far as when we're comparing transoral laser surgery versus IMRT radiation therapy for an early glottic tumor, is one better than the other or is it just talking about the logistics of, "With radiation, you're going to be going every day for six weeks. With surgery, you have to have general anesthesia and this thing," and it's about choosing which pros and cons of each? From an outcomes, is one better than the other, swallowing, voice quality?
[Dr. Bharat Panuganti]
It's a really good question. I think that's where this becomes interesting with survival equipoise. You start to consider other things like what the patient wants. I think it's easy to look at population-level data and say that there are basically equivalent functional outcomes between radiation and surgery. I don't think it's appropriate to extrapolate for early glottic cancer, population level, functional outcomes to an individual patient.
I think if you look at T2 stage 2 cancers, there is such a significant spectrum of what a T2 cancer might entail. If someone has hypomobility because they have this massive tumor that's involving the thyroarytenoid muscle, I think on average, those patients are probably better off getting radiation, but if a T2 tumor simply involves a portion of the vestibular fold and a portion of the subglottis that you can clear endoscopically, that's a patient that does better with surgery.
If a patient gets radiation and they have some difficulty swallowing solid food, and it makes it uncomfortable for them to go out and have dinner, in a public setting with friends and family, you compare that to someone that doesn't have swallowing problems but is slightly dysphonic in a way that they're rough. It's something that people notice. How do you compare one versus the other? They're fundamentally different sequelae of two different treatment options.
I think that's where it becomes really difficult for people without truly understanding the granularity of decision-making in this process to say that one modality is better than the other. Of course, how it's done makes a difference. Their radiation oncologists are not all the same. Surgeons are not all the same. Patients aren't all the same. I think that having all the information in hand so you can have a really educated and informed conversation with the patient about the possibilities so that they can make a decision on their own, that's really where I think early glottic cancer care becomes so interesting is it really is a sophisticated conversation.
You can't just look at proportions and numbers. You really have to talk to someone and have a really truly intimate conversation. I think as ENTs, we have this unique opportunity to affect people functionally in a way that I frankly don't think other specialties can. We're helping people smell, helping people hear, helping people voice, interact with the world in a meaningful way. Early glottic cancer, I think, is really emblematic of that.
[Dr. Gopi Shah]
Yes. It's truly like a personalized care.
[Dr. Bharat Panuganti]
That's right.
[Dr. Gopi Shah]
Individualized personalized care. Amazing. If we start to round it out, wrap it up, I feel like that was a beautiful ending message, but do you have any final pearls, Bharat, that you want to leave our listeners with?
[Dr. Bharat Panuganti]
No, I think I would say that if you have a voice problem, it's something that shouldn't be underestimated. I think in general, this idea that only people that have smoked are susceptible to early vocal fold cancers or early larynx cancers, that assumption shouldn't be made. I think in general, voice problems shouldn't be underestimated and whether or not it's a cancer doesn't mean it can't be solved surgically or medically. I would say generally not to make assumptions.
I think as a message to anybody managing early glottic cancer, my message is treat the patient with kindness and respect and understand their needs and wants, and desires because the decision-making process, even though it's not something that can kill them, is something that's really important for their life. It's how they voice, it's how they swallow, and I think it's our responsibility to be considerate of that.
Podcast Contributors
Dr. Bharat Panuganti
Dr. Bharat Panuganit is an otolaryngologist and airway surgeon at Washington University in St. Louis, Missouri.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, November 12). Ep. 199 – Advances in Early Glottic Cancer Treatment Options [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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