- Email: [email protected]
Carbon dioxide laser microsurgery for early glottic carcinoma
Otolaryngology–Head and Neck Surgery (2006) 134, 911-915
ORIGINAL RESEARCH
Carbon dioxide laser microsurgery for early glottic carcinoma Gian Peppino Ledda, MD, and Roberto Puxeddu, MD, Cagliari, Italy OBJECTIVES: To define the oncologic efficacy of transoral endoscopic CO2 laser surgery in early glottic carcinoma. METHODS: A retrospective study of 103 patients with glottic carcinoma (14 Tis, 68 pT1a, 14 pT1b, and 7 pT2) treated from October 1993 to June 2001. Surgical treatment included endoscopic CO2 laser cordectomies according to the classification of the European Laryngological Society. RESULTS: According to the Kaplan-Meier method, the probability of remaining free of local recurrence 5 years after primary surgery alone was 100% for the Tis, 96.05% for the T1, and 100% for the T2. Local control at 5 years after exclusive CO2 laser salvage surgery was 98.03%. The probability of remaining free of local recurrence 5 years after any type of salvage surgery was 100%. Laryngeal preservation was achieved in 100% of the cases. CONCLUSIONS: According to the present series, endoscopic CO2 laser surgery is an effective treatment for early glottic cancer. EBM rating: C-4 © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
cilities, and cost-effectiveness ratio of the procedures,10,11 since the approach is tailored to each patient. CO2 laser endoscopic cordectomy for early glottic carcinoma is considered an oncologically effective procedure with a mean cure rate of 91.5%,11 with excellent functional results that can be achieved by improving diagnostic procedure as well as therapeutic techniques.12 Selected cases of recurrences after radiotherapy failure can also be advantageously managed with endoscopic CO2 laser salvage surgery.13 In the present paper, we retrospectively evaluate the role of CO2 laser endoscopic microsurgery for the treatment of Tis, T1, and selected cases of T2 glottic carcinoma, classified according to the American Joint Committee on Cancer.14
MATERIALS AND METHODS
arly glottic cancer can be adequately managed with radiotherapy or surgery1 and within surgery, several effective techniques are available to the surgeon. Cordectomy via thyrotomy,2 horizontal glottectomy,3 open vertical partial laryngectomy,4 supracricoid laryngectomy,5 and carbon dioxide (CO2) laser endoscopic resection6 are well recognized to be effective in the treatment of early glottic cancer and can be selected case by case as the most appropriate tool in relation to the tumor extent. Otherwise, additional factors influence the treatment choice of early glottic carcinoma such as status of the larynx and anatomic limitations,7 patient age and general health conditions,8 patient’s voice expectations and quality of life,9 medical fa-
From October 1993 to June 2001, 103 Caucasian patients with glottic carcinoma were submitted to surgery by the same surgeon (R.P.), at the Section of Otorhinolaryngology of the Department of Surgical Sciences and Organ Transplantations of Cagliari University. Mean follow-up was 5.9 years. Only 3 were female (2.9%), and the ages ranged from 39 to 85 years (mean age, 64.1; median, 64.9). According to the 1997 American Joint Committee on Cancer,14 the tumors were classified as Tis (14 patients), T1a (68 patients), T1b (14 patients), and T2 cases with impairment of vocal cord mobility (7 patients). The involvement of the anterior commissure was present in 22 of 103 patients (21.3%). The only inclusion criterion to select the patients for the endoscopic approach was the complete exposure of the glottis by the Kleinsasser laser laryngoscopes modified by
From the Department of Surgical Sciences and Organ Transplantations, Section of Otorhinolaryngology, University of Cagliari. Reprint requests: Roberto Puxeddu, MD, Department of Surgical Sci-
ences and Organ Transplantations, Section of Otorhinolaryngology, Via Ospedale 54, 09100 Cagliari, Italy. E-mail address: [email protected].
E
0194-5998/$32.00 © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2005.10.049
912
Otolaryngology–Head and Neck Surgery, Vol 134, No 6, June 2006
Table 1 Stage and type of cordectomy according to the Classification of the Endoscopic Cordectomies proposed by European Laryngological Society Working Committee Stage
Type I
Type II
Type III
Type IV
Type V
Total
Tis T1a T1b T2 Total
8 2 10
5 14 1 20
1 27 3 31
7 3 2 12
18 7 5 30
14 68 14 7 103
Rudert with the Riecker-Kleinsasser suspension system (Storz, Tuttlingen, Germany). A Sharplan 1030 carbon dioxide laser with an Acuspot 712 micromanipulator (Sharplan, Tel Aviv, Israel) set on the superpulsed mode (2 to 5 watts, 270-micron spot size) was used. Massive involvement of the anterior commissure was considered as an exclusion criterion for the endoscopic approach. When the anterior commissure was involved or for T2 tumors, the deep extension of the tumor was evaluated by preoperative CT scans. Pre- and intraoperative diagnostic assessment included videolaryngoscopy, videolaryngostroboscopy, and intraoperatively, rigid endoscopy by 0-degree, 70-degree, and 120degree telescopes. On the basis of the apparent extension of the neoplasm, we performed five different types of endoscopic laser cordectomies (Table 1) according to the classification proposed by the European Laryngological Society in 2000:1 surgical treatment included 10 type I (subepithelial cordectomy), 20 type II (subligamental cordectomy), 31 type III (transmuscular cordectomy), 12 type IV (total cordectomy), and 30 type V (extended cordectomy). Cancer resection was always performed by an en bloc removal technique. For histological evaluation, the specimen was oriented by staining the superior edge with marking ink and examined by permanent sections. All patients were subsequently examined by an angled rigid or a flexible fiberoptic laryngo-pharyngoscope for a period ranging from 37 to 141.3 months (mean, 71.8). The surgical protocol was reviewed and approved by the local Institutional Review Board of our institution.
Statistical Methods The cumulative probability of surviving was analyzed according to the Kaplan-Meier method. With the method, we studied the disease-free interval according to local control results. The standard error (SE) was also computed. The statistical significance of the differences in cumulative survival tables was tested with the log rank test, considering an ␣ error of 5% (ie, significance when P ⬍ 0.05). Software packages used. The data were collected using the Microsoft Excel electronic sheet. The statistical packages used for the analysis were EpiInfo 6.04b and SPSS for Windows release 6.0.2.
RESULTS There have been no intraoperative or postoperative complications related to the surgical procedure in any of the 103 patients. No feeding tube was inserted and no tracheostomy was performed at the end of the procedure or in the postoperative period. Mean hospitalization time was 2.6 days, including the hospitalization time for the group of the 10 patients submitted to re-excision. At histology, 13 patients had at least one positive margin but not more than two in the specimen, while 90 subjects had a clear margin resection. Few options were adopted when positive margins were present (13 cases): endoscopic laser re-excision (10 patients), postoperative radiotherapy (1 patient, total dose 74 Gy), and wait-and-see policy (2 patients). After re-excision, histological evaluation showed carcinoma in only 2 of 10 specimens and mild dysplasia in one case but with free margins. No recurrences were seen in these 13 patients. Recurrences occurred in 3 of 103 patients, with recurrent carcinoma identified between 3 and 12 months postsurgery (mean, 10.1). All 3 patients were alive and free of disease after endoscopic laser re-excision (initially T1b), endoscopic laser re-excision and radiotherapy (initially T1b), and open partial vertical laryngectomy followed by radiotherapy (initially T1a), respectively. No patient in this study developed nodal disease during the follow-up period. According to the Kaplan-Meier method, the probability of remaining free of local recurrence 5 years after primary surgery was 100% for the Tis group (14 patients), 96.05% (Fig 1) for the T1 group (82 patients), and 100% for the T2 group (7 patients). Local control at 5 years after exclusive CO2 laser salvage surgery was 98.03% (SE 1.38%) for all stages (Fig 1). The probability of remaining free of local recurrence 5 years after any type of salvage surgery was 100% for all the classes. Laryngeal preservation was achieved in 100% of the cases. Anterior commissure spread resulted in a difference (not statistically significant, P ⫽ 0.6) in local control between the group of patients without (81/103 patients) and with anterior commissure involvement (22/103 patients), 96.54% (SE 2.43%) and 87.5% (SE 11.69%) respectively. Seven patients (6.7%) died of unrelated diseases, according to the Kaplan-Meier method overall survival at 5 years
Ledda and Puxeddu
Carbon dioxide laser microsurgery for early glottic . . .
913
Figure 1 Local control at 5 years after exclusive CO2 laser salvage surgery for all stages and disease-free survival 5 years after primary surgery for the T1 group only (*).
was 91.79% (Fig 2). Seven patients (6.7%) developed a second primary malignancy.
DISCUSSION Laryngofissure with cordectomy and glottectomy were routinely used until 1993 to treat early glottic carcinoma in our section. After that time, endoscopic laser surgery was used
Figure 2
for nearly all the cases of Tis and T1, and for selected cases of T2 glottic carcinoma. Although open laryngeal procedures offer good oncologic results for the treatment of early glottic carcinoma, a more conservative endoscopic approach with laser excision has the undoubted advantages of a shorter hospitalization, less morbidity, and better functional results. The transoral approach to glottic carcinoma dates back to 1920, when Lynch15 described his experience in a group of 9 patients,
Overall survival at 5 years.
914
Otolaryngology–Head and Neck Surgery, Vol 134, No 6, June 2006
but only in 1975 Strong16 described endolaryngeal CO2 laser surgery as a promising technique for the management of early glottic carcinoma. The three-dimensional control of the surgical field under microscopic visualization, with a clear view of the macroscopic extent of the neoplasm and depth of the resection, the usually short operative and hospitalization times, and the low morbidity of the procedure with oncologic results as good as those obtained with open surgery, resulted in a prompt acceptance of the approach for surgical management of early laryngeal carcinoma.17 Moreover, the goal of the recently developed phonomicrosurgical approaches is to achieve the best compromise between oncological radicality and vocal function with a minimal impact on quality of life.9,12 We routinely apply the concept of excisional biopsy18 with a resulting different extension of the cordectomy, thus minimizing treatment morbidity without altering the cure rate. Careful examination with multiple sectioning and mapping of the tumor by inking the superior margin of the specimen (which was routinely performed in all of our cases submitted to endoscopy) appeared to be extremely helpful in making a decision for postoperative re-excision, radiotherapy, or a wait-and-see policy. Involvement of the deep margin and/or lateral margins was identified in 13 patients after the primary procedure. Only 1 patient underwent postoperative radiotherapy (total dose of 74 Gy), since after a type IV cordectomy it was not possible to extend the resection to the thyroid cartilage. After an adequate counseling, 10 patients showing positive margins at primary surgery required reoperation with a second endoscopic procedure at least 2 weeks after the first surgery. At histology, specimens from the second procedure showed in all cases free margins, and the tumor was detected in the center of the specimen in only 2 patients. As a consequence, only 20% of the patients showing positive margins at primary surgery were truly to be reoperated. Such an over-treatment, although limited to a small group of patients (8/103), could be avoided just by a strict wait-andsee policy. We believe that in the event of positive margins after the primary approach, a correct patient counseling, as carried out in all our cases, should be considered imperative since the second procedure could be unnecessary. When histology showed a positive single superficial margin but the intra-operative view by the surgeon gave the appearance of a macroscopically clear margin (2 patients), we did not recommend a second surgery to the patient and a wait-and-see policy was carefully applied. No recurrences were noted in these 2 patients. In the event of histologically positive margin(s) and an intra-operative view of narrow margins (10 patients), an enlargement of the surgical area was proposed to the patient. As a result of such a policy, according to the KaplanMeier method the probability of 5-year local control with CO2 laser alone was 98.03% with laryngeal preservation in all patients after any type of salvage surgery (Fig 1).
Involvement of the anterior commissure has been frequently associated with local recurrence,4,7,16 since cartilage invasion can be favored by the lack of perichondrium where the anterior commissure tendons reach the cartilage.19 In the present series, 21.35% of the patients (22/103) had involvement of the anterior commissure, although it was never an involvement of the whole anterior commissure region. Fixation of the anterior third of both vocal cords and deep extension to the cartilage, as preoperatively defined by videolaryngoscopy and CT, were considered as a contraindication for the endoscopic approach. In this 22 patients, histology always showed the deep margin free of tumor. Therefore, we found a not statistically significant difference in local control (P ⫽ 0.6) between the group of patients without (96.54%; SE 2.43%) and with anterior commissure involvement (87.5%; SE 11.69%). Elective neck dissection was never performed, and no patient developed nodal metastases during the follow-up period. Our data are in accord with previously reported findings that elective neck treatment in N0 early glottic carcinomas, in the form of neck dissection or radiation therapy, is not strictly indicated.20
CONCLUSIONS According to the present study, endoscopic CO2 laser surgery is an efficacious treatment for early-stage glottic cancer. The use of adapted endoscopic cordectomies, arising from the basic concept of the excisional biopsy, for Tis, T1, and selected cases of T2 glottic carcinoma, appears to be an oncologically effective procedure, thus minimizing treatment morbidity without altering the cure rate. The authors thank B. Johnston for editing the manuscript.
REFERENCES 1. Remacle M, Eckel HE, Antonelli AR, et al. Endoscopic cordectomy. A proposal for a classification by the Working Committee, European Laryngological Society. Eur Arch Otorhinolaryngol 2000;257:227–31. 2. Muscatello L, Laccourreye O, Biacabe B, et al. Laryngofissure and cordectomy for glottic carcinoma limited to the mid third of the mobile true vocal cord. Laryngoscope 1997;107:1507–10. 3. Puxeddu R, Argiolas F, Bielamowicz S, et al. Surgical therapy of T1 and selected cases of T2 glottic carcinoma: cordectomy, horizontal glottectomy and CO2 laser endoscopic resection. Tumori 2000;86: 277– 82. 4. Laccourreye O, Weinstein G, Brasnu D, et al. Vertical partial laryngectomy: a critical analysis of local recurrence. Ann Otol Rhinol Laryngol 1991;100:68 –71. 5. Laccourreye O, Muscatello L, Laccourreye L, et al. Supracricoid partial laryngectomy with cricohyoidoepiglottopexy for “early” glottic carcinoma classified as T1-T2N0 invading the anterior commissure. Am J Otolaryngol 1997;18:385–90. 6. Davis RK, Hadley K, Smith ME. Endoscopic vertical partial laryngectomy. Laryngoscope 2004;114:236 – 40. 7. Zeitels SM. Infrapetiole exploration of the supraglottis for exposure of the anterior glottal commissure. J Voice 1998;12:117–22. 8. Leon X, Quer M, Agudelo D, et al. Influence of age on laryngeal carcinoma. J Ann Otol Rhinol Laryngol 1998;107:164 –9.
Ledda and Puxeddu
Carbon dioxide laser microsurgery for early glottic . . .
9. Smith JC, Johnson JT, Cognetti DM, et al. Quality of life, functional outcome, and costs of early glottic cancer. Laryngoscope 2003;113: 68 –76. 10. Myers EN, Wagner RL, Johnson JT. Microlaryngoscopic surgery for T1 glottic lesions: a cost-effective option. Ann Otol Rhinol Laryngol 1994;103:28 –30. 11. Brandenburg JH. Laser cordotomy versus radiotherapy: an objective cost analysis. Ann Otol Rhinol Laryngol 2001;110:312– 8. 12. Peretti G, Piazza C, Balzanelli C, et al. Vocal outcome after endoscopic cordectomies for Tis and T1 glottic carcinomas. Ann Otol Rhinol Laryngol 2003;112:174 –9. 13. Puxeddu R, Piazza C, Mensi MC, et al. Carbon dioxide laser salvage surgery after radiotherapy failure in T1 and T2 glottic carcinoma. Otolaryngol Head Neck Surg 2004;130:84 – 8. 14. Fleming ID, Cooper JS, Henson DE, et al, editors. American Joint Committee on Cancer. 5th ed. Philadelphia: Lippincott; 1997. p. 41– 6.
915
15. Lynch RC. Intrinsic carcinoma of the larynx with a second report of cases operated on by suspension and dissection. Trans Am Laryngol Assoc 1920;42:119 –26. 16. Strong MS. Laser excision of carcinoma of the larynx. Laryngoscope 1975;85:1286 –9. 17. Eckel HE. Local recurrences following transoral laser surgery for early glottic carcinoma: frequency, management, and outcome. Ann Otol Rhinol Laryngol 2001;110:7–15. 18. Blakeslee D, Vaughan CW, Shapshay SM, et al. Excisional biopsy in the selective management of T1 glottic cancer: a three-year follow-up study. Laryngoscope 1984;94:488 –94. 19. Olofsson J, Williams GT, Rider WD, et al. Anterior commissure carcinoma. Primary treatment with radiotherapy in 57 patients. Arch Otolaryngol 1972;95:230 –5. 20. Yang CY, Andersen PE, Everts EC, et al. Nodal disease in purely glottic carcinoma: is elective neck treatment worthwhile? Laryngoscope 1998;108:1006 – 8.
ORIGINAL RESEARCH
Carbon dioxide laser microsurgery for early glottic carcinoma Gian Peppino Ledda, MD, and Roberto Puxeddu, MD, Cagliari, Italy OBJECTIVES: To define the oncologic efficacy of transoral endoscopic CO2 laser surgery in early glottic carcinoma. METHODS: A retrospective study of 103 patients with glottic carcinoma (14 Tis, 68 pT1a, 14 pT1b, and 7 pT2) treated from October 1993 to June 2001. Surgical treatment included endoscopic CO2 laser cordectomies according to the classification of the European Laryngological Society. RESULTS: According to the Kaplan-Meier method, the probability of remaining free of local recurrence 5 years after primary surgery alone was 100% for the Tis, 96.05% for the T1, and 100% for the T2. Local control at 5 years after exclusive CO2 laser salvage surgery was 98.03%. The probability of remaining free of local recurrence 5 years after any type of salvage surgery was 100%. Laryngeal preservation was achieved in 100% of the cases. CONCLUSIONS: According to the present series, endoscopic CO2 laser surgery is an effective treatment for early glottic cancer. EBM rating: C-4 © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
cilities, and cost-effectiveness ratio of the procedures,10,11 since the approach is tailored to each patient. CO2 laser endoscopic cordectomy for early glottic carcinoma is considered an oncologically effective procedure with a mean cure rate of 91.5%,11 with excellent functional results that can be achieved by improving diagnostic procedure as well as therapeutic techniques.12 Selected cases of recurrences after radiotherapy failure can also be advantageously managed with endoscopic CO2 laser salvage surgery.13 In the present paper, we retrospectively evaluate the role of CO2 laser endoscopic microsurgery for the treatment of Tis, T1, and selected cases of T2 glottic carcinoma, classified according to the American Joint Committee on Cancer.14
MATERIALS AND METHODS
arly glottic cancer can be adequately managed with radiotherapy or surgery1 and within surgery, several effective techniques are available to the surgeon. Cordectomy via thyrotomy,2 horizontal glottectomy,3 open vertical partial laryngectomy,4 supracricoid laryngectomy,5 and carbon dioxide (CO2) laser endoscopic resection6 are well recognized to be effective in the treatment of early glottic cancer and can be selected case by case as the most appropriate tool in relation to the tumor extent. Otherwise, additional factors influence the treatment choice of early glottic carcinoma such as status of the larynx and anatomic limitations,7 patient age and general health conditions,8 patient’s voice expectations and quality of life,9 medical fa-
From October 1993 to June 2001, 103 Caucasian patients with glottic carcinoma were submitted to surgery by the same surgeon (R.P.), at the Section of Otorhinolaryngology of the Department of Surgical Sciences and Organ Transplantations of Cagliari University. Mean follow-up was 5.9 years. Only 3 were female (2.9%), and the ages ranged from 39 to 85 years (mean age, 64.1; median, 64.9). According to the 1997 American Joint Committee on Cancer,14 the tumors were classified as Tis (14 patients), T1a (68 patients), T1b (14 patients), and T2 cases with impairment of vocal cord mobility (7 patients). The involvement of the anterior commissure was present in 22 of 103 patients (21.3%). The only inclusion criterion to select the patients for the endoscopic approach was the complete exposure of the glottis by the Kleinsasser laser laryngoscopes modified by
From the Department of Surgical Sciences and Organ Transplantations, Section of Otorhinolaryngology, University of Cagliari. Reprint requests: Roberto Puxeddu, MD, Department of Surgical Sci-
ences and Organ Transplantations, Section of Otorhinolaryngology, Via Ospedale 54, 09100 Cagliari, Italy. E-mail address: [email protected].
E
0194-5998/$32.00 © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2005.10.049
912
Otolaryngology–Head and Neck Surgery, Vol 134, No 6, June 2006
Table 1 Stage and type of cordectomy according to the Classification of the Endoscopic Cordectomies proposed by European Laryngological Society Working Committee Stage
Type I
Type II
Type III
Type IV
Type V
Total
Tis T1a T1b T2 Total
8 2 10
5 14 1 20
1 27 3 31
7 3 2 12
18 7 5 30
14 68 14 7 103
Rudert with the Riecker-Kleinsasser suspension system (Storz, Tuttlingen, Germany). A Sharplan 1030 carbon dioxide laser with an Acuspot 712 micromanipulator (Sharplan, Tel Aviv, Israel) set on the superpulsed mode (2 to 5 watts, 270-micron spot size) was used. Massive involvement of the anterior commissure was considered as an exclusion criterion for the endoscopic approach. When the anterior commissure was involved or for T2 tumors, the deep extension of the tumor was evaluated by preoperative CT scans. Pre- and intraoperative diagnostic assessment included videolaryngoscopy, videolaryngostroboscopy, and intraoperatively, rigid endoscopy by 0-degree, 70-degree, and 120degree telescopes. On the basis of the apparent extension of the neoplasm, we performed five different types of endoscopic laser cordectomies (Table 1) according to the classification proposed by the European Laryngological Society in 2000:1 surgical treatment included 10 type I (subepithelial cordectomy), 20 type II (subligamental cordectomy), 31 type III (transmuscular cordectomy), 12 type IV (total cordectomy), and 30 type V (extended cordectomy). Cancer resection was always performed by an en bloc removal technique. For histological evaluation, the specimen was oriented by staining the superior edge with marking ink and examined by permanent sections. All patients were subsequently examined by an angled rigid or a flexible fiberoptic laryngo-pharyngoscope for a period ranging from 37 to 141.3 months (mean, 71.8). The surgical protocol was reviewed and approved by the local Institutional Review Board of our institution.
Statistical Methods The cumulative probability of surviving was analyzed according to the Kaplan-Meier method. With the method, we studied the disease-free interval according to local control results. The standard error (SE) was also computed. The statistical significance of the differences in cumulative survival tables was tested with the log rank test, considering an ␣ error of 5% (ie, significance when P ⬍ 0.05). Software packages used. The data were collected using the Microsoft Excel electronic sheet. The statistical packages used for the analysis were EpiInfo 6.04b and SPSS for Windows release 6.0.2.
RESULTS There have been no intraoperative or postoperative complications related to the surgical procedure in any of the 103 patients. No feeding tube was inserted and no tracheostomy was performed at the end of the procedure or in the postoperative period. Mean hospitalization time was 2.6 days, including the hospitalization time for the group of the 10 patients submitted to re-excision. At histology, 13 patients had at least one positive margin but not more than two in the specimen, while 90 subjects had a clear margin resection. Few options were adopted when positive margins were present (13 cases): endoscopic laser re-excision (10 patients), postoperative radiotherapy (1 patient, total dose 74 Gy), and wait-and-see policy (2 patients). After re-excision, histological evaluation showed carcinoma in only 2 of 10 specimens and mild dysplasia in one case but with free margins. No recurrences were seen in these 13 patients. Recurrences occurred in 3 of 103 patients, with recurrent carcinoma identified between 3 and 12 months postsurgery (mean, 10.1). All 3 patients were alive and free of disease after endoscopic laser re-excision (initially T1b), endoscopic laser re-excision and radiotherapy (initially T1b), and open partial vertical laryngectomy followed by radiotherapy (initially T1a), respectively. No patient in this study developed nodal disease during the follow-up period. According to the Kaplan-Meier method, the probability of remaining free of local recurrence 5 years after primary surgery was 100% for the Tis group (14 patients), 96.05% (Fig 1) for the T1 group (82 patients), and 100% for the T2 group (7 patients). Local control at 5 years after exclusive CO2 laser salvage surgery was 98.03% (SE 1.38%) for all stages (Fig 1). The probability of remaining free of local recurrence 5 years after any type of salvage surgery was 100% for all the classes. Laryngeal preservation was achieved in 100% of the cases. Anterior commissure spread resulted in a difference (not statistically significant, P ⫽ 0.6) in local control between the group of patients without (81/103 patients) and with anterior commissure involvement (22/103 patients), 96.54% (SE 2.43%) and 87.5% (SE 11.69%) respectively. Seven patients (6.7%) died of unrelated diseases, according to the Kaplan-Meier method overall survival at 5 years
Ledda and Puxeddu
Carbon dioxide laser microsurgery for early glottic . . .
913
Figure 1 Local control at 5 years after exclusive CO2 laser salvage surgery for all stages and disease-free survival 5 years after primary surgery for the T1 group only (*).
was 91.79% (Fig 2). Seven patients (6.7%) developed a second primary malignancy.
DISCUSSION Laryngofissure with cordectomy and glottectomy were routinely used until 1993 to treat early glottic carcinoma in our section. After that time, endoscopic laser surgery was used
Figure 2
for nearly all the cases of Tis and T1, and for selected cases of T2 glottic carcinoma. Although open laryngeal procedures offer good oncologic results for the treatment of early glottic carcinoma, a more conservative endoscopic approach with laser excision has the undoubted advantages of a shorter hospitalization, less morbidity, and better functional results. The transoral approach to glottic carcinoma dates back to 1920, when Lynch15 described his experience in a group of 9 patients,
Overall survival at 5 years.
914
Otolaryngology–Head and Neck Surgery, Vol 134, No 6, June 2006
but only in 1975 Strong16 described endolaryngeal CO2 laser surgery as a promising technique for the management of early glottic carcinoma. The three-dimensional control of the surgical field under microscopic visualization, with a clear view of the macroscopic extent of the neoplasm and depth of the resection, the usually short operative and hospitalization times, and the low morbidity of the procedure with oncologic results as good as those obtained with open surgery, resulted in a prompt acceptance of the approach for surgical management of early laryngeal carcinoma.17 Moreover, the goal of the recently developed phonomicrosurgical approaches is to achieve the best compromise between oncological radicality and vocal function with a minimal impact on quality of life.9,12 We routinely apply the concept of excisional biopsy18 with a resulting different extension of the cordectomy, thus minimizing treatment morbidity without altering the cure rate. Careful examination with multiple sectioning and mapping of the tumor by inking the superior margin of the specimen (which was routinely performed in all of our cases submitted to endoscopy) appeared to be extremely helpful in making a decision for postoperative re-excision, radiotherapy, or a wait-and-see policy. Involvement of the deep margin and/or lateral margins was identified in 13 patients after the primary procedure. Only 1 patient underwent postoperative radiotherapy (total dose of 74 Gy), since after a type IV cordectomy it was not possible to extend the resection to the thyroid cartilage. After an adequate counseling, 10 patients showing positive margins at primary surgery required reoperation with a second endoscopic procedure at least 2 weeks after the first surgery. At histology, specimens from the second procedure showed in all cases free margins, and the tumor was detected in the center of the specimen in only 2 patients. As a consequence, only 20% of the patients showing positive margins at primary surgery were truly to be reoperated. Such an over-treatment, although limited to a small group of patients (8/103), could be avoided just by a strict wait-andsee policy. We believe that in the event of positive margins after the primary approach, a correct patient counseling, as carried out in all our cases, should be considered imperative since the second procedure could be unnecessary. When histology showed a positive single superficial margin but the intra-operative view by the surgeon gave the appearance of a macroscopically clear margin (2 patients), we did not recommend a second surgery to the patient and a wait-and-see policy was carefully applied. No recurrences were noted in these 2 patients. In the event of histologically positive margin(s) and an intra-operative view of narrow margins (10 patients), an enlargement of the surgical area was proposed to the patient. As a result of such a policy, according to the KaplanMeier method the probability of 5-year local control with CO2 laser alone was 98.03% with laryngeal preservation in all patients after any type of salvage surgery (Fig 1).
Involvement of the anterior commissure has been frequently associated with local recurrence,4,7,16 since cartilage invasion can be favored by the lack of perichondrium where the anterior commissure tendons reach the cartilage.19 In the present series, 21.35% of the patients (22/103) had involvement of the anterior commissure, although it was never an involvement of the whole anterior commissure region. Fixation of the anterior third of both vocal cords and deep extension to the cartilage, as preoperatively defined by videolaryngoscopy and CT, were considered as a contraindication for the endoscopic approach. In this 22 patients, histology always showed the deep margin free of tumor. Therefore, we found a not statistically significant difference in local control (P ⫽ 0.6) between the group of patients without (96.54%; SE 2.43%) and with anterior commissure involvement (87.5%; SE 11.69%). Elective neck dissection was never performed, and no patient developed nodal metastases during the follow-up period. Our data are in accord with previously reported findings that elective neck treatment in N0 early glottic carcinomas, in the form of neck dissection or radiation therapy, is not strictly indicated.20
CONCLUSIONS According to the present study, endoscopic CO2 laser surgery is an efficacious treatment for early-stage glottic cancer. The use of adapted endoscopic cordectomies, arising from the basic concept of the excisional biopsy, for Tis, T1, and selected cases of T2 glottic carcinoma, appears to be an oncologically effective procedure, thus minimizing treatment morbidity without altering the cure rate. The authors thank B. Johnston for editing the manuscript.
REFERENCES 1. Remacle M, Eckel HE, Antonelli AR, et al. Endoscopic cordectomy. A proposal for a classification by the Working Committee, European Laryngological Society. Eur Arch Otorhinolaryngol 2000;257:227–31. 2. Muscatello L, Laccourreye O, Biacabe B, et al. Laryngofissure and cordectomy for glottic carcinoma limited to the mid third of the mobile true vocal cord. Laryngoscope 1997;107:1507–10. 3. Puxeddu R, Argiolas F, Bielamowicz S, et al. Surgical therapy of T1 and selected cases of T2 glottic carcinoma: cordectomy, horizontal glottectomy and CO2 laser endoscopic resection. Tumori 2000;86: 277– 82. 4. Laccourreye O, Weinstein G, Brasnu D, et al. Vertical partial laryngectomy: a critical analysis of local recurrence. Ann Otol Rhinol Laryngol 1991;100:68 –71. 5. Laccourreye O, Muscatello L, Laccourreye L, et al. Supracricoid partial laryngectomy with cricohyoidoepiglottopexy for “early” glottic carcinoma classified as T1-T2N0 invading the anterior commissure. Am J Otolaryngol 1997;18:385–90. 6. Davis RK, Hadley K, Smith ME. Endoscopic vertical partial laryngectomy. Laryngoscope 2004;114:236 – 40. 7. Zeitels SM. Infrapetiole exploration of the supraglottis for exposure of the anterior glottal commissure. J Voice 1998;12:117–22. 8. Leon X, Quer M, Agudelo D, et al. Influence of age on laryngeal carcinoma. J Ann Otol Rhinol Laryngol 1998;107:164 –9.
Ledda and Puxeddu
Carbon dioxide laser microsurgery for early glottic . . .
9. Smith JC, Johnson JT, Cognetti DM, et al. Quality of life, functional outcome, and costs of early glottic cancer. Laryngoscope 2003;113: 68 –76. 10. Myers EN, Wagner RL, Johnson JT. Microlaryngoscopic surgery for T1 glottic lesions: a cost-effective option. Ann Otol Rhinol Laryngol 1994;103:28 –30. 11. Brandenburg JH. Laser cordotomy versus radiotherapy: an objective cost analysis. Ann Otol Rhinol Laryngol 2001;110:312– 8. 12. Peretti G, Piazza C, Balzanelli C, et al. Vocal outcome after endoscopic cordectomies for Tis and T1 glottic carcinomas. Ann Otol Rhinol Laryngol 2003;112:174 –9. 13. Puxeddu R, Piazza C, Mensi MC, et al. Carbon dioxide laser salvage surgery after radiotherapy failure in T1 and T2 glottic carcinoma. Otolaryngol Head Neck Surg 2004;130:84 – 8. 14. Fleming ID, Cooper JS, Henson DE, et al, editors. American Joint Committee on Cancer. 5th ed. Philadelphia: Lippincott; 1997. p. 41– 6.
915
15. Lynch RC. Intrinsic carcinoma of the larynx with a second report of cases operated on by suspension and dissection. Trans Am Laryngol Assoc 1920;42:119 –26. 16. Strong MS. Laser excision of carcinoma of the larynx. Laryngoscope 1975;85:1286 –9. 17. Eckel HE. Local recurrences following transoral laser surgery for early glottic carcinoma: frequency, management, and outcome. Ann Otol Rhinol Laryngol 2001;110:7–15. 18. Blakeslee D, Vaughan CW, Shapshay SM, et al. Excisional biopsy in the selective management of T1 glottic cancer: a three-year follow-up study. Laryngoscope 1984;94:488 –94. 19. Olofsson J, Williams GT, Rider WD, et al. Anterior commissure carcinoma. Primary treatment with radiotherapy in 57 patients. Arch Otolaryngol 1972;95:230 –5. 20. Yang CY, Andersen PE, Everts EC, et al. Nodal disease in purely glottic carcinoma: is elective neck treatment worthwhile? Laryngoscope 1998;108:1006 – 8.