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ORIGINAL ARTICLE
Year : 2018  |  Volume : 8  |  Issue : 1  |  Page : 6-9

Oncologic outcomes of transoral laser microsurgery for early glottic carcinoma


Voice Clinic, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India

Date of Web Publication8-May-2019

Correspondence Address:
Dr. Shashank Gupta
Voice Clinic, Superspeciality Building 1st Floor, Deenanath Mangeshkar Hospital, Erandwane, Pune - 411 004, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jlv.JLV_13_18

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   Abstract 


Introduction: Laryngeal carcinoma comprises 2%–5% of all malignant diseases. Treatment options for early glottic cancers are open partial laryngectomy, radiotherapy (RT), and transoral laser microsurgery (TLM). The goals of management of early glottic carcinoma are complete oncological clearance, organ preservation, and functional preservation (voice, swallowing, and airway). This study aims to review oncologic results of TLM for management of early glottic carcinoma at our institute. Methodology: Patients with early glottic squamous cell carcinoma, i.e., Tis, T1, and T2 stage lesions managed with TLM from January 2011 to 2014 were included in the study. Medical records were analyzed to acquire data. Results: Sixty-six patients underwent TLM for management of early glottic cancer between 2011 and 2014. Tumor-free margins were obtained after TLM in all 10 cases with Tis. For T1a, T1b, and T2 lesions, surgery obtained tumor-free margins in 89.5%, 77.8%, and 77.8% cases, respectively. Nine patients were found to have a positive margin and they underwent revision surgery. The overall local cure rate obtained by TLM was 92.4%. The overall 3-year survival rate was 98.5%. One patient died of myocardial infarction 2 years after TLM, giving a disease-specific 3-year survival rate of 100%. Conclusion: TLM is a safe and effective treatment option for management of early glottic cancer. Its outcomes are comparable to those of RT, and it has lesser cost, treatment duration, and morbidity.

Keywords: Cancer, larynx, oncological outcomes, transoral laser surgery


How to cite this article:
Gandhi S, Santocildes A, Gupta S. Oncologic outcomes of transoral laser microsurgery for early glottic carcinoma. J Laryngol Voice 2018;8:6-9

How to cite this URL:
Gandhi S, Santocildes A, Gupta S. Oncologic outcomes of transoral laser microsurgery for early glottic carcinoma. J Laryngol Voice [serial online] 2018 [cited 2019 Sep 19];8:6-9. Available from: http://www.laryngologyandvoice.org/text.asp?2018/8/1/6/257806




   Introduction Top


Laryngeal carcinoma comprises 2%–5% of all malignant diseases. Glottic lesions form 50%–60% of laryngeal cancers.[1] The incidence of male-to-female is 4:1 with 90% occurring in people over 40 years of age with no identified racial predilection. 95% of laryngeal cancers are squamous cell carcinomas (SCCs).[2]

Treatment options for early glottic cancers are open partial laryngectomy, radiotherapy (RT), and transoral laser microsurgery (TLM). The goals of management of early glottic carcinoma are complete oncological clearance, organ preservation, and functional preservation (voice, swallowing, and airway). The choice of treatment should depend on these factors. TLM surgical techniques and RT have undergone significant advancement in the past few years leading to a decrease in open procedures.

In our institution, TLM is advocated as the primary treatment modality in early glottic carcinoma. It provides higher laryngeal preservation rate, shorter hospital stay, lower morbidity, superior functional outcomes, and option of additional treatment in case of recurrence.[3]

This study aims to review the oncologic results of TLM for management of early glottic carcinoma at our institute. This study will contribute to the existing literature about the effectiveness of TLM in treating early glottic carcinoma.


   Methodology Top


Patients with early glottic SCC, i.e., Tis, T1, and T2 stage lesions managed with TLM from January 2011 to 2014 were included in the study.

Medical records were analyzed to acquire data (age, sex, histopathologic results, tumor class, and credibility on follow-up). Routine preoperative workup included assessment of lesion with high-definition (HD) flexible videolaryngostroboscopy. Suspected malignant lesions were identified based on the stroboscopic findings. Contrast-enhanced computed tomography scan of the neck was done for all such cases to assess the extent of disease and any locoregional spread. Patients were then informed and counseled regarding the suspected nature of the lesion and available treatment options. Sixty-six patients chose to undergo TLM for management of their disease.

For the surgical procedure, high-frequency jet ventilation was used in all patients. The suspected lesion and its extent were visualised with straight and angled rigid HD scopes (0,30,70 degree). Intra-operative biopsy was taken and sent for frozen section analysis. Once malignancy was confirmed, appropriate laser cordectomy (based on the standardized European Laryngology Society classification)[4] was carried out. All lesions were removed via en bloc resection with 1–2 mm margin of normal tissue.

Postoperative follow-up of patients was done by HD flexible videolaryngostroboscopy. Visits were scheduled 1 and 3 weeks after the surgery. After 3 weeks, patients were evaluated on a 6-weekly basis for the 1st year, every 12 weeks in the 2nd and 3rd years, and 6 monthly follow-up on the succeeding years. IBM SPSS Software Ver. 25 (IBM Analytics, USA) program was used for the statistical analysis of the outcome.


   Results Top


Sixty-six patients underwent TLM for management of early glottic cancer between 2011 and 2014. 60 (90.9%) were males and 6 (9.1%) were females with a mean age of 54.15 years.

T-stage of the lesion was distributed as summarized in [Table 1]. All patients underwent laser cordectomies depending on the site and extent of lesion [Table 1]. A margin of 1–2 mm of normal tissue as seen on microscopic examination was taken.
Table 1: Characteristics of the study population (n=66)

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Tumor-free margins were obtained after TLM in all 10 cases with Tis. For T1a, T1b, and T2 lesions, surgery obtained tumor-free margins in 89.5%, 77.8%, and 77.8% cases, respectively. Nine patients were found to have a positive margin, and they underwent revision surgery. All patients have been under follow-up for 3–6 years.

Of 66 patients, 8 developed recurrence of tumor [Table 2]. Four patients with recurrence underwent RT as secondary treatment. Two of them again developed recurrence post-RT and underwent total laryngectomy. One patient developed gross recurrence to an extent that revision TLM was not suitable. He refused RT and underwent total laryngectomy. The remaining three patients with recurrence underwent revision TLM. The overall local cure rate obtained by TLM was 92.4% [Table 3].
Table 2: Recurrence (n=8)

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Table 3: Results according to staging

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A total of 3 patients underwent total laryngectomy. Laryngeal preservation was therefore possible in 63 of 66 patients, giving a laryngeal preservation rate of 95.4%. All patients have been under follow-up. The overall 3-year survival rate was 98.5%. One patient died of myocardial infarction 2 years after TLM, giving a disease-specific 3-year survival rate of 100%.


   Discussion Top


TLM is an emerging technique for the management of laryngeal malignancies.[3],[5] It has replaced conventional open surgery mainly because of decreased morbidity and better organ preservation rates. It may also play a significant role in the setting of advanced laryngeal cancer by providing surgical salvage which can substantially prolong laryngectomy-free survival.[6]

The local control, laryngeal preservation, and survival rates of TLM in early laryngeal cancer have been similar to cases managed with RT or open partial laryngectomy.[7]

RT is less cost-effective and has a longer treatment duration. Open partial laryngectomy destroys normal laryngeal anatomy and can impair laryngeal function. Major surgical morbidities such as aspiration pneumonia, fistula, infection, bleeding, subglottic stenosis, and permanent dependence on gastrostomy have been reported.[6],[7],[8]

TLM has very few documented intraoperative or postoperative major complications and is generally deemed a safe procedure.[7],[9] The most common reported complication is postoperative bleeding.[9] Pita et al.[10] reported postoperative bleeding complications in 3 (2.34%) of 128 patients treated for laryngeal cancer by TLM. In this study, the authors did not experience any postoperative bleeding complications.

In this study, Tis–T2 stages were considered as early glottic carcinoma, although there is still no standard definition on which stages are included in this criterion. Some authors consider T1–T2 lesions only and others include Tis lesion.[3]

Estomba et al.[11] reported a local cure rate of 79.3% with first TLM for early glottic and Bocciolini et al.[12] achieved a rate of 89.9%. In this study, single TLM was able to achieve a local control rate of 85.7%. After revision surgery, the overall local control rate using TLM alone was 92.4%. It is comparable to the results obtained by Estomba et al.[11] with 98.3% and Bocciolini et al.[12] at 92.4%. Peretti et al.[13] achieved a local control rate of 93.5% in Tis, 95% in T1, and 85.6% in T2 stage lesions using CO2 laser alone.

Early laryngeal cancer has been correlated with high local control rates and favorable outcomes. Brandstorp-Boesen et al.[14] reported that T1 tumors had a lower risk of recurrence than T2 lesions. The risk of recurrence differs with the type of modality of treatment, subsite, tumor margins, N status, and T status. The results of this study also reflect this to be true with a recurrence rate of 13.3% for T1 lesions and 22.2% for T2 lesions.

Involvement of the anterior commissure is a controversial issue while choosing a treatment modality. Three of eight patients who developed recurrence in this study had growth involving anterior commissure. Mendelsohn et al.[15] stated that anterior commissure involvement implies a negative prognostic indicator regardless of the treatment of choice; it is known to be aggressive and demonstrates poor oncologic and functional outcomes. Hoffman et al.[16] also stated that for patients with Tis–T2 glottic cancer, anterior commissure involvement had lower local control, disease-specific survival, and laryngeal preservation.

Disease-specific survival rate in this study was 100% for Tis, T1, and T2 stage glottic cancer over 3 years. This is comparable to other reports in literature. Estomba et al.[11] achieved a 3-year specific survival rate of 98.3%, while Bocciolini et al.[12] reported 3-year specific survival rate of 98.7%. Peretti et al.[13] reported disease-specific survival rates of 100%, 99%, and 98.3%, respectively, in Tis, T1, and T2 lesions. After salvage therapy, our laryngeal preservation rate was 95.4% similar from the published works of Estomba et al.[11] and Bocciolini et al.[12] The findings of this study are also comparable to those of Delsupehe et al.[17] and Steiner[18] who achieved similar local control rates and disease-specific survival rates.

It is important to note that our study focuses only on TLM and its oncologic outcomes. Limitations of the study include small number of patients, absence of control group to compare results, and voice qualities were not evaluated.


   Conclusion Top


TLM is a safe and effective treatment option for the management of early glottic cancer. Its outcomes are comparable to those of RT, and it has lesser cost, treatment duration, and morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mastronikolis NS, Papadas TA, Goumas PD. Head and neck: Laryngeal tumors: An overview. Atlas Genet Cytogenet Oncol Haematol 2009;13:888-93.  Back to cited text no. 1
    
2.
Armstrong W, Vokes D, Verma S. Malignant Tumors of the Larynx. Cummings Otolaryngology – Head and Neck Surgery. 6th ed., Ch. 106. Elsevier Science (Medical): Philadelphia; 2015. p. 1610.  Back to cited text no. 2
    
3.
Sjögren EV. Transoral laser microsurgery in early glottic lesions. Curr Otorhinolaryngol Rep 2017;5:56-68.  Back to cited text no. 3
    
4.
Remacle M, Van Haverbeke C, Eckel H, Bradley P, Chevalier D, Djukic V, et al. Proposal for revision of the European laryngological society classification of endoscopic cordectomies. Eur Arch Otorhinolaryngol 2007;264:499-504.  Back to cited text no. 4
    
5.
Rubinstein M, Armstrong WB. Transoral laser microsurgery for laryngeal cancer: A primer and review of laser dosimetry. Lasers Med Sci 2011;26:113-24.  Back to cited text no. 5
    
6.
Sandulache VC, Kupferman ME. Transoral laser surgery for laryngeal cancer. Rambam Maimonides Med J 2014;5:1-10.  Back to cited text no. 6
    
7.
Hsin LJ, Fang TJ, Chang KP, Fang KH, Tsang NM, Chen YL, et al. Transoral endoscopic CO2 laser microsurgery for early laryngeal cancers. Chang Gung Med J 2009;32:517-25.  Back to cited text no. 7
    
8.
Sheney A, Sharma V, Chavan P. Transoral microsurgery vs. radiotherapy for early glottic cancer: Study at tertiary care center in India. Int J Head Neck Surg 2017;8:15-20.  Back to cited text no. 8
    
9.
Canis M, Martin A, Ihler F, Wolff HA, Kron M, Matthias C, et al. Transoral laser microsurgery in treatment of pT2 and pT3 glottic laryngeal squamous cell carcinoma – Results of 391 patients. Head Neck 2014;36:859-66.  Back to cited text no. 9
    
10.
Pita E, Cajelli A, Latourrette D. Transoral surgery for laryngeal cancer: Bleeding complications. J Otolaryngol ENT Res 2016;4:113.  Back to cited text no. 10
    
11.
Estomba C, Reinoso F, Velasquez A. Transoral CO2 Laser Microsurgery Outcomes for early Glottic Carcinoma T1 – T2. Int Arch Otorhinolaryngol 2016;20:212-7.  Back to cited text no. 11
    
12.
Bocciolini C, Presutti L, Laudadio P. Oncological outcome after CO2 laser cordectomy for early-stage glottic carcinoma. Acta Otorhinolaryngol Ital 2005;25:86-93.  Back to cited text no. 12
    
13.
Peretti G, Nicolai P, Redaelli De Zinis LO, Berlucchi M, Bazzana T, Bertoni F, et al. Endoscopic CO2 laser excision for tis, T1, and T2 glottic carcinomas: Cure rate and prognostic factors. Otolaryngol Head Neck Surg 2000;123:124-31.  Back to cited text no. 13
    
14.
Brandstorp-Boesen J, Sorum Falk R, Evensen F, Boysen M, Brondbo K. Risk of recurrence in laryngeal cancer. PLos One 2006;11:e0164068.  Back to cited text no. 14
    
15.
Mendelsohn AH, Kiagiadaki D, Lawson G, Remacle M. CO2 laser cordectomy for glottic squamous cell carcinoma involving the anterior commissure: Voice and oncologic outcomes. Eur Arch Otorhinolaryngol 2015;272:413-8.  Back to cited text no. 15
    
16.
Hoffmann C, Hans S, Sadoughi B, Brasnu D. Identifying outcome predictors of transoral laser cordectomy for early glottic cancer. Head Neck 2016;38 Suppl 1:E406-11.  Back to cited text no. 16
    
17.
Delsupehe KG, Zink I, Lejaegere M, Bastian RW. Voice quality after narrow-margin laser cordectomy compared with laryngeal irradiation. Otolaryngol Head Neck Surg 1999;121:528-33.  Back to cited text no. 17
    
18.
Steiner W. Experience in endoscopic laser surgery of malignant tumours of the upper aero-digestive tract. Adv Otorhinolaryngol 1988;39:135-44.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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