Purpose / Aim

To illustrate the decision-making process and surgical techniques in managing locally advanced poorly differentiated thyroid cancer, including an organ-preserving strategy followed by salvage laryngectomy in the setting of radiation-induced laryngeal necrosis.

Background

I am a high-volume thyroid surgeon with dedicated experience in managing aggressive thyroid cancers. In this presentation, I will discuss a patient with locally advanced poorly differentiated thyroid carcinoma who underwent larynx-preserving resection followed by adjuvant radiotherapy. Three months postoperatively, the patient developed radiation-induced laryngeal necrosis that failed conservative management. Salvage total laryngectomy and tracheal resection with free-flap reconstruction were subsequently performed.

Description

Through operative video footage and perioperative documentation, ı will highlight:

- Selection criteria for larynx-preserving surgery in locally advanced thyroid cancer
- Oncologic and functional considerations
- Management of post-radiation complications including laryngeal necrosis
- Techniques and outcomes of salvage laryngectomy and tracheal resection with free-tissue reconstruction

Speaker

Jaiganesh Manickavasagam (Jai Manick), MS(ENT), FRCS(ORL-HNS) Consultant Head & Neck Surgeon and Clinical Director for Cancer Services, NHS Tayside Founder & Director, Dundee Institute of Head & Neck Education (DIHNE)

Overview

Transoral Laser Microsurgery (TLM) has fundamentally transformed the management of laryngeal malignancy by providing organ-preserving, function-sparing alternatives to open surgery and radiotherapy. Over the past 13 years, I have developed one of the largest single-surgeon TLM experiences in the UK, comprising more than 600 cases across the full spectrum of laryngeal disease, from Tis and early glottic carcinoma to carefully selected T3 tumours. This keynote will present a comprehensive, outcomes-driven analysis of this experience, framed within the evolution of laser technology and its impact on precision oncologic surgery.

Scientific and Clinical Focus

A central theme of this lecture is the technological evolution of laser systems in laryngeal surgery, particularly the complementary roles of CO₂ and 445-nm blue laser platforms. While CO₂ remains the gold standard for precise cutting and margin control due to its high absorption in water, the introduction of the blue laser has added a new dimension to photoangiolytic and haemoglobin-selective tissue interaction. Through comparative case series and video-based illustration, this keynote will demonstrate how these two technologies can be used synergistically rather than competitively.

The CO₂ laser allows cold-like, oncologically precise excision of bulky tumours, facilitating en-bloc or controlled piecemeal resections with excellent histological margins. In contrast, the blue laser offers exceptional haemostasis and vocal fold preservation, particularly in highly vascular tumours, papillomatosis, dysplasia, and early glottic cancer, enabling bloodless surgery with superior functional outcomes. The lecture will show how appropriate wavelength selection improves margin control, reduces thermal injury, and enhances post-operative voice and swallowing.

Advanced Airway and Surgical Techniques

Laser laryngeal surgery demands meticulous airway control and interdisciplinary coordination. Drawing on experience as Director of DIHNE and Principal Investigator on multiple national trials, this keynote will share practical strategies for safe and efficient airway management, including jet ventilation, laser-safe tubes, and exposure techniques for challenging anterior commissure and supraglottic tumours. Evidence-based discussion will address the en-bloc versus piece-meal resection debate and how technique selection influences oncologic and functional outcomes.

Outcomes, Complications and Evidence

Longitudinal outcome data from this 600-case cohort will be presented, including local control, laryngeal preservation, voice and swallowing outcomes, and retreatment rates. An honest and practical discussion of complications—airway fires, secondary haemorrhage, chondritis, and stenosis—will be included, focusing on prevention, early recognition, and MDT-led management.

Conclusion and Future Direction

Using high-definition surgical videos, this keynote will bridge clinical science with surgical craftsmanship, illustrating how modern laser technology enables safe escalation from early-stage disease to complex organ-preserving surgery in advanced laryngeal cancer. This presentation will provide IFOS delegates with a contemporary, evidence-based roadmap for mastering TLM in the era of precision laryngeal oncology.

Transoral Robotic Surgery rapresents a defined and well standarzided surgical therapy for oropharyngeal cancer, despite many open questions remain, particularly regarding the role of first-line treatment in comparison with radiotherapy and chemiotherapy.

Background: HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) exhibits a markedly better prognosis than HPV-negative disease, prompting interest in treatment de-escalation to reduce long-term toxicity without compromising survival. Multiple prospective trials are evaluating approaches to tailor treatment intensity based on individual risk profiles.

Methods: This review summarizes current de-escalation strategies in HPV-positive OPSCC, including reduced-dose radiation, omission or minimization of concurrent chemotherapy, and primary surgical approaches such as transoral robotic surgery (TORS). Major clinical trials, including NRG-HN002, ECOG-ACRIN 3311, PATHOS, and ORATOR, were analyzed for oncologic outcomes, toxicity profiles, and patient-reported quality of life.

Results: Several studies demonstrate that de-escalated regimens—such as 60 Gy radiation with or without chemotherapy, or TORS followed by risk-adapted adjuvant therapy—achieve comparable locoregional control and overall survival to standard treatment, with improved functional outcomes. Importantly, patient selection is critical, relying on factors such as tumor stage, nodal burden, smoking history, and pathological features. Ongoing trials are refining risk stratification tools and assessing biomarkers for therapy individualization.

Conclusions: De-escalation strategies for HPV-positive OPSCC represent a paradigm shift toward more personalized, less morbid therapy. While early-phase studies show promising results, mature data from phase III trials are needed to define safe standards of care. Careful patient selection and multidisciplinary coordination remain essential to ensure oncologic efficacy while improving long-term quality of life.