Melanie Cole: UAB is offering patients a unique surgical option for management of early laryngeal cancer that's not offered anywhere else in the south. Welcome to UAB Med Cast. I'm Melanie Cole, and joining me today is Dr. Bharat Panuganti. He's an assistant professor in the Department of Otolaryngology with a clinical focus of loreal Surgery at UAB Medicine, and he's here to discuss and highlight  Transoral laser microsurgery management of early stage larynx cancer. Dr. Panuganti, thank you so much for joining us today. I'd like you to tell us a little bit about larynx cancer and the scope of the problem that we're discussing here today. What have you seen in the trends?

Bharat Panuganti, MD: So laryngeal cancer incidence is coming down annually. And that is going hand in hand with the decreased frequency of tobacco use. The most recent figures that I saw I think indicated that there were 13,000 new laryngeal cancer diagnoses annually in the United States. The Laryngal cancer primarily originates from the Gladys or the vocal folds. About 60 to 70% of new diagnoses come from the vocal folds. And that is the bulk of what I treat with transoral, laser microsurgery here at UAB.

Melanie Cole: So speak to us a little bit about diagnoses and clinical presentation. When is this presenting itself? What do you see as far as symptoms, and what are some of the prognostic diagnostic tools that you're using?

Bharat Panuganti, MD: Good thing about laryn cancer and specifically about glottic cancer is that even minor changes to the vocal folds will result potentially in pretty significant changes in a patient's voice. So oftentimes the reason that someone ends up in my clinic typically they've been seen by another ENT, but primary complaint amongst people with vocal fold cancers is voice change. And that can happen even with early stage T1 disease and even not cancer. So carcin inside you and dysplasia can affect the vibration of the vocal fold and can result in a change in someone's voice.

Typically the way we diagnose it clinically we use high resolution endoscopy. And we do that one of two ways. We either stick a scope through someone's nose or stick a scope in someone's mouth in order to evaluate the larynx. But as with any other cancer, the way it's diagnosed pathologically is with a biopsy in the operating room.

Melanie Cole: Are Only tobacco smokers at risk for this type of cancer?

Bharat Panuganti, MD: That's a good question. Historically, if you look at the American Academy of Otolaryngology website, I believe the website still says that over 90 something percent of larynx cancer patients are smokers. But I think that trend is changing. And I have some unpublished data, which I'm happy to talk about now, but I'm looking at a cohort of about 500 early glottic cancer patients, and when I say early glottic cancer, I mean T1 and T2. 30% of that cohort were non-smokers are effectively non-smoker. So, A total tobacco use number of years, which was less than five years. And that's pretty remarkable because that is completely antithetical to the empirical historical understanding of the kinds of patients that are prone to developing larynx cancer.

Melanie Cole: So due to the sensitivity of this type of cancer and the intricate nature, before we get into some of the current treatment options, either any non-surgical. Treatment options that you would look to conservative at first.

Bharat Panuganti, MD: Yeah, so the majority of people around the country are offered radiotherapies, so radiation is treatment modailty. And it depends on the region, but I think nationally that figure probably stands at 80 to 85% of patients with T1 and T2 glottic cancers end up getting radiation. I think a big part of that is for this surgery to be offered effectively, safely, and in a way that has the best opportunity to preserve someone's voice, requires subspecialty training, which isn't available in large spots of the country. But yes radiotherapy is what's most commonly offered.

Melanie Cole: So now I'd like you to speak about current treatment options and how endoscopic instrumentation, coupled with improved imaging and localization techniques have been used adequately to resect tumors with minimum damage to surrounding tissues that allows surgeons to access those hard to reach areas of the mouth and throat. Speak a little bit about transoral laser micro surgery.

Bharat Panuganti, MD: Yeah. So transferable Laser microsurgery or tlm which is the acronym that goes by most commonly originated in the 1970s in Boston when the carbon dioxide laser was first coupled with a microscope such that we could start to use the laser for laryngeal surgeries. So just to give some historical context, dating back to the 18 hundreds when the first total laryngectomy was performed, all of the procedures that were being offered before for definitive treatment were open surgeries, be it a total laryngectomy or partial laryngectomy. But since the 1970s, we've developed instruments and lasers and techniques to make it such that early glottic cancer specifically can be removed.

Effectively with good oncologic clearance without really affecting a patient's voice negatively. And the way that's done is we use instruments that expose the larynx through the mouth, so direct laryngoscopy. And there are a number of lasers that we can use to resect a cancer. And the laser that I use that probably the minority of surgeons use across the country, something called the potassium tight Neal Phosphate Laser. KTP laser. And without delving too much into the nuance, there are two different kinds of lasers.

There are a blade of lasers or cutting lasers. And cutting lasers have a Chromaform, like carbon dioxide is attracted to water, which is. Basically present in all our tissues. The KTP laser is attracted to hemoglobin as it's Chromaform, which gives me the opportunity to really titrate the dose of the energy to just the tumor and the area around the tumor. And what we found is ultra narrow margins, meaning if I remove the tumor in only a very narrow region around the tumor, we get the same oncologic outcomes as we do with any other technique.

And it's really because of this opportunity for me to resect narrow margins, but still tell a patient, hey, I can treat your cancer with the same efficacy as any other technique, including radiotherapy. It's because of that, that I have the opportunity to tell patients that I can preserve their voice while still treating their cancer. And I think that's the beauty of this technique.

Melanie Cole: Well, It certainly is fascinating and speak a little bit about some of the other technologies that you might consider. And while you're doing that, please tell us how much the experience of the physician and surgeon matters in this case, because these are very sensitive areas and as we've said these can really have devastating effects on the patient. So speak about experience and any other technologies you'd like to mention.

Bharat Panuganti, MD: Yeah I'll answer your second question first. So, I think surgeon experience is absolutely critical for a couple of different reasons. One When I am in the operating room ablating a tumor really requires an appreciation for the effect that the laser has on the tissue, on normal tissue versus tumor for you to understand how much to remove. So I think that someone that doesn't do this very often would find it difficult to have the same sort of outcomes and more than that, being able to surveil these patients in the clinic afterwards requires high resolution, high quality endoscopy which from a cost perspective can be quite prohibitive.

But because this is all I do I can justify paying for that technology. And in terms of other things that are on the horizon improving trans laser microsurgery which is already a pretty good technique is my sort of clinical research focus now. And I think there are a couple things on the horizon. As I mentioned before, what we look at in the operating room is basically I'm looking under a microscope to see how the tissue changes when I'm ablating through it. It's very much contingent on surgeon experience, but to a certain degree it is also subjective. And what I want to do is mitigate the effect of surgeon experience on a surgeon's ability to do the surgery.

And there are a couple active avenues of research here at UAB that I'm spearheading, but basically we're looking to see if there's some, a fluorescent dye that we can use to help us determine the boundaries of the tumor, such that the tumor section becomes contingent on simply looking at a field to see where there's fluorescence uptake as opposed to the more subjective experience of simply looking to see what the tissue does differently when it's tumor versus not when you laser through it. We're also looking to see if tours is an. For laryngeal cancers. And I think there are a couple big benefits potentially to using robotics in laryngeal cancer surgery.

One, it gives you the opportunity to use a flexible endoscope to get a very up close and personal look of the larynx in a way that is not always easy to do with the equipment that we have. Two, it has the opportunity to improve ergonomics. And three the dye that I was talking about, currently the modality that we use to actually see that in the operating room requires a special near infrared imaging technology that's already coupled with the Da Vinci surgical robot. That's basically what we're looking at now from a surgical technique perspective to see if we can change the efficacy of TLM, improve it from simply being 80 to 90% to 95 to a hundred percent.

Melanie Cole: So Doctor, given the complexity and with increasingly advanced treatment algorithms, as you're just talking about that add new options to your armamentarium of available therapies, how important is the multidisciplinary. For these patients because they can be more complex because it is possibly disabling, socially isolating, these kinds of cancers can really have that psychological and psychosocial effect on patients? Can you please speak about the multidisciplinary approach in your team?

Bharat Panuganti, MD: Yeah. Everything we do really in laryngeal surgery is multidisciplinary. At the voice center here, we have a big group of very experienced speech pathologists. As you said surgery for laryngeal cancer can be quite disabling from both a voice and a swallow perspective. So, I ask all patients that I operate on to meet with the speech pathologist both before, during, and after treatment so that we can anticipate and treat swallowing voice problems as we come up. But even beyond that, there's always multiple ways to treat cancer. I always ask that patients at least hear from a radiation oncologist so that the full spectrum of treatment options, they're informed before making the decision to pursue surgery. So yeah, everything about laryngeal cancer care is very much a multidisciplinary effort.

Melanie Cole: So as we get ready to wrap up, I'd like you to speak to other providers now about what makes you unique at UAB Medicine. They're referring their patients. When do you feel that is the best time to do that? And when they're counseling their patients, Please tell them how you would like them to approach this because of all of the avenues that we've spoken about today?

Bharat Panuganti, MD: You know, I think the primary message that I would hope to convey is that all patients independent of their smoking history, even if it was five or 10 years, are theoretically at risk for developing laryngeal cancer. So I'd say that if they're, if a patient has a voice complaint that doesn't go away spontaneously, that I would consider sending them over to our clinic so that we can take a look endoscopically and make sure that there isn't a mask that's causing the voice change. And I think that's primarily the thing is just to be aware of the possibility of aryn cancer from people that don't smoke. And I think we're gonna see that with more f. In the future, but I think we're very much in that era now. So that'd be my primary recommendation.

Melanie Cole: It's a pretty exciting time to be in your field. Dr. Panuganti, thank you so much for joining us today, and for more information or to refer your patient to UAB Medicine, you can call the MIST line at 1-800-UAB-MIST or by visiting our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole.