Resection margins and other prognostic factors regarding surgically treated glottic carcinomas

Management and Oncologic Outcomes of Close and Positive Margins after Transoral CO2 Laser Microsurgery for Early Glottic Carcinoma

BACKGROUND

The present study analyzed the impact of margin status on local control and survival, and the management of close/positive margins after transoral CO₂ laser microsurgery for early glottic carcinoma.

METHODS

351 patients (328 males, 23 females, mean age 65.6 years) underwent surgery. We identified the following margin statuses: negative, close superficial (CS), close deep (CD), positive single superficial (SS), positive multiple superficial (MS), and positive deep (DEEP).

RESULTS

A total of 286 patients (81.5%) had negative margins, 23 (6.5%) had close margins (8 CS, 15 CD) and 42 (12%) had positive margins (16 SS, 9 MS, 17 DEEP). Among the 65 patients with close/positive margins, 44 patients underwent enlargement, 6 radiotherapy and 15 follow-up. Twenty-two patients (6.3%) recurred. Patients with DEEP or CD margins showed a higher risk of recurrence (hazard ratios of 2.863 and 2.537, respectively), compared to patients with negative margins. Local control with laser alone, overall laryngeal preservation and disease-specific survival decreased significantly in patients with DEEP margins (57.5%, 86.9% and 92.9%, p < 0.05).

CONCLUSIONS

Patients with CS or SS margins could be safely submitted to follow-up. In the case of CD and MS margins, any additional treatment should be discussed with the patient. In the case of DEEP margin, additional treatment is always recommended.

Shrinkage of specimens after CO2 laser cordectomy: an objective intraoperative evaluation

PURPOSE

The margin status after CO₂ laser cordectomy for glottic carcinoma may influence prognosis. There are no studies assessing the possible bias due to anatomic changes of the specimens for shrinkage. The authors evaluated the intraoperative shrinkage of specimens immediately after transoral CO₂ laser microsurgery (CO₂ TOLMS) to improve the understanding and the interpretation of surgical margins.

METHODS

This is a prospective study involving a consecutive cohort of 23 patients (19 males, 4 females, mean age 69.9 years, range 42-83 years) with early glottic carcinoma treated by CO₂ TOLMS from February 2017 to April 2019. The anteroposterior shrinkage of the specimen, of the tumor, and of the anterior and posterior margins was measured intraoperatively with a cross table reticle glass micrometer ruler, inserted into the eyepiece of the surgical microscope.

RESULTS

The mean shrinkage of the mucosal specimen from intralaryngeal measurement to post-resection measurement was 3.8 ± 0.3 mm, resulting in an average loss of 29% of the anteroposterior length (p < 0.01). The anteroposterior length of both the tumor and the margins after resection significantly decreased, but the shrinkage of the anterior and posterior margins was significantly greater than the shrinkage of the tumor (49% versus 20% and 45% versus 20%, p < 0.01).

CONCLUSION

The present study demonstrates significant shrinkage of specimens after CO₂ TOLMS, especially in the anteroposterior length of the vocal cords, and justifies the good oncological results for specimens with close and single positive superficial margins. Follow-up versus a second surgical look policy could be safely suggested in cases of close superficial and single positive superficial margins.

[Determination of pathological margin of hypopharyngeal cancer by terahertz time-domain spectroscopy system]

Objective:To investigate the accuracy of the terahertz system in differentiating hypopharyngeal cancer from normal tissue and its role in determining the pathological incised margin of hypopharyngeal cancer. Method:The transplantation model of hypopharyngeal cancer in 5-week-old male BALB/c nude mice were established by subcutaneous injection. The obtained transplanted tumor specimens were pathologically diagnosed to determine the extent of tumor tissue. Tumor tissue, normal tissue and paracellular tissue of transplantation tumor were scanned by terahertz time-domain spectroscopy. The differential spectral data were obtained through the detection of frozen tissue sections and paraffin tissue sections, respectively. The results were compared by t-test. Result:The tarahertz absorption coefficient of tumor tissues was higher than that of normal tissues, and the difference was statistically significant when the detection frequency was greater than 0.48 THz in frozen sections（P<0.05）. In the paraffin sections, the difference was statistically significant within the effective spectrum range of 0.2-1.6 THz（P<0.01）. The difference of refractive index between tumor tissue and normal tissue was significant in specimens treated in two ways（P<0.01）. The absorption coefficient of adjacent tissue felt between that of normal tissue and tumor tissue. Conclusion:Terahertz technology can distinguish tumor tissues and normal tissues accurately, and can detect the spectral changes in adjacent tissues sensitively. Therefore, terahertz technology may become another tool for the judgment of pathologic margin.

Prognostic role of resection margin in open oncologic laryngeal surgery: survival analysis of a cohort of 139 patients affected by squamous cell carcinoma

INTRODUCTION

The treatment of laryngeal squamous cell carcinoma needs accurate risk stratification, in order to choose the most suitable therapy. The prognostic significance of resection margin is still highly debated, considering the contradictory results obtained in several studies regarding the survival rate of patients with a positive resection margin.

OBJECTIVE

To evaluate the prognostic role of resection margin in terms of survival and risk of recurrence of primary tumour through survival analysis.

METHODS

Between 2007 and 2014, 139 patients affected by laryngeal squamous cell carcinoma underwent partial or total laryngectomy and were followed for mean of 59.44±28.65 months. Resection margin status and other variables such as sex, age, tumour grading, pT, pN, surgical technique adopted, and post-operative radio- and/or chemotherapy were investigated as prognostic factors.

RESULTS

45.32% of patients underwent total laryngectomy, while the remaining subjects in the cohort underwent partial laryngectomy. Resection margins in 73.39% of samples were free of disease, while in 21 patients (15.1%) anatomo-pathological evaluation found one of the margins to be close; in 16 subjects (11.51%) an involved resection margin was found. Only 6 patients (4.31%) had a recurrence, which occurred in 83.33% of these patients within the first year of follow-up. Disease specific survival was 99.24% after 1 year, 92.4% after 3 years, and 85.91% at 5 years. The multivariate analysis of all covariates showed an increased mortality rate only with regard to pN (HR=5.043; p=0.015) and recurrence (HR=11.586; p=0.012). Resection margin did not result an independent predictor (HR=0.757; p=0.653).

CONCLUSIONS

Our study did not recognize resection margin as an independent prognostic factor; most previously published papers lack unanimous, methodological choices, and the cohorts of patients analyzed are not easy to compare. To reach a unanimous agreement regarding the prognostic value of resection margins, it would be necessary to carry out meta-analyses on studies sharing definition of resection margin, methodology and post-operative therapeutic choices.

Evidence for critical role of Tie2/Ang1 interaction in metastatic oral cancer

Angiopoietin-1 (Ang1) is a binding partner of endothelial cell-specific tyrosine-protein kinase receptor (Tie2), which serves important roles in vascular development and angiogenesis. Tie2 is closely associated with the metastasis of oral squamous cell carcinomas (OSCCs) however, little is known about the correlation between Tie2 and Ang1. In the present study, the functional mechanisms of the Tie2/Ang1 interaction were investigated using Tie2 overexpressed (oeTie2) OSCC cells and recombinant Ang1 protein. oeTie2 cells had increased cell-cell and cell-extracellular matrix adhesions compared with the control cells. Additionally, the adhesive activities increased following treatment with exogenous Ang1, indicating that Ang1 directly enhances Tie2 functions. In the clinical OSCC data from 10 cases positive for regional lymph node metastasis, all cases were negative for Tie2 expression and eight cases (80%) were negative for Ang1 expression. These results suggest that Tie2 and Ang1 serve important roles in cancer metastasis and may be potential biomarkers and therapeutic targets for OSCC metastasis.

"Watchful observation" follow-up scheme after endoscopic CO2 laser treatment for small glottic carcinomas: A retrospective study of 93 cases

OBJECTIVES

Evaluate the clinical outcome of patients treated with CO₂ laser surgery for early-stage glottic carcinomas followed up with 3-month laryngoscopy regardless of tumor grade and margins.

DESIGN

Case series.

SETTING

Retrospective review of the clinical records of patients treated at the ENT department of a tertiary university hospital.

PARTICIPANTS AND METHOD

Clinical records from patients with early-stage glottic carcinomas (Tis/T2) treated with curative intent by CO₂ laser surgery in a ten-year period were evaluated. Regardless of tumor margin status, patients underwent fiber endoscopy 6 weeks after surgery and a systematic second look by direct laryngoscopy under general anesthesia at 3 months.

MAIN OUTCOME MEASURES

Local control, laryngeal preservation rate.

RESULTS

Ninety-three patients were included. Disease control was obtained in 90/93 cases. Laryngeal preservation rate was 96.8%. Twenty patients had a local residual disease or recurrence after the first laser surgery, but 17 were salvaged (85%). Local residual disease and recurrence were more frequent in patients with advanced disease (T1b/T2), invasion of anterior commissure and "non-safe" margins.

CONCLUSION

The proposed follow-up scheme might be a valuable option, but with caution for positive or unevaluable margins as the latter is an independent risk factor for local recurrence. An early laser excision procedure (eg, within the first two months after surgery) or an alternative strategy may be discussed in this situation. "Watchful observation" should be reserved for compliant patients only so that the risk of missing potential recurrences is minimised.

Evidence and evidence gaps of laryngeal cancer surgery

Surgical treatment of laryngeal cancer has been established for decades. In addition to total laryngectomy, which was first performed in 1873, a large number or organ preservation surgical techniques, like open partial laryngectomy, transoral laser microsurgery, and transoral robotic surgery have been developed. Studies on laryngeal cancer surgery are mainly retrospective case series and cohort studies. The evolution of chemoradiation protocols and their analysis in prospective randomized trials have led to an increasing acceptance of non-surgical treatment procedures. In addition to an improvement of prognosis, in recent years the preservation of function and maintenance of life quality after primary therapy of laryngeal cancer has increasingly become the focus of therapy planning. Significant late toxicity after chemoradiation has been identified as an important issue. This leads to a reassessment of surgical concepts and initiation of studies on laryngeal cancer surgery which was additionally stimulated by the advent of transoral robotic surgery in the US. Improving the evidence base of laryngeal cancer surgery by successful establishment of surgical trials should be the future goal.

Overexpression of TMOD1 is associated with enhanced regional lymph node metastasis in human oral cancer

Tropomodulin1 (TMOD1), which regulates the length and depolymerization of actin filaments by binding to the pointed end of the actin filament, has been reported to be a powerful diagnostic marker for ALK-negative anaplastic large-cell lymphoma; however, little is known about the relevance of TMOD1 in the behavior of oral squamous cell carcinoma (OSCC). We evaluated TMOD1 expression in OSCC-derived cell lines and primary OSCC samples (n=200) using quantitative reverse transcriptase-polymerase chain reaction, immunoblotting and semi-quantitative immunohistochemistry. We also analyzed the clinical correlation between TMOD1 expression status and clinical parameters in patients with OSCC and performed a prospective study using 40 primary OSCC samples. TMOD1 expression was upregulated significantly (p<0.05) in OSCC in vitro and in vivo compared with normal counterparts. TMOD1 expression also was correlated significantly (p=0.0199 and p=0.0064, respectively) with regional lymph node metastasis (RLNM) and 5-year survival rates. This prospective study also showed that high TMOD1 expression was seen in 12 (75%) of 16 cases in RLNM-positive patients and 9 (37.5%) of 24 cases in RLNM-negative patients. The current data provide the first evidence that TMOD1 expression is a critical biomarker for RLNM and prognosis of patients with OSCC.

ANGPTL4 regulates the metastatic potential of oral squamous cell carcinoma

Lymph node metastasis is a major factor for poor prognosis in oral squamous cell carcinoma (OSCC). However, the molecular mechanisms of lymph node metastasis are unclear. We determined that angiopoietin-like protein 4 (ANGPTL4) mRNA and protein expression were increased in OSCC cells established from the primary site in metastatic cases. In addition, ANGPTL4 expression in biopsy specimens was correlated with the presence of lymph node metastasis. Therefore, our initial findings suggest that OSCC cells expressing ANGPTL4 may possess metastatic ability. Furthermore, cell culture supernatants from OSCC cells that metastasized to the lymph node contain ANGPTL4 and promote invasive ability. These findings suggest that secreted ANGPTL4 may affect the invasive ability of OSCC. Moreover, the rates of positive ANGPTL4 expression at the primary site were significantly higher in the lymph node metastasis group. These results demonstrate that ANGPTL4 contributes to OSCC metastasis by stimulating cell invasion. Therefore, ANGPTL4 is a potential therapeutic target for preventing cancer metastasis.

Management of locally advanced laryngeal cancer

Background

Management of advanced laryngeal cancer is complex and ideal strategy is yet to be defined. This study evaluates the experience of a single head and neck oncologic centre in the management of T4 laryngeal cancer.

Methods

Retrospective assessment of cases primarily treated for T4a squamous cell carcinoma of the larynx, between 1980 and 2007, at a tertiary referral center.

Results

A total of 384 cases were studied. Five-year disease specific survival was 56.2% and local control 87.4%. Regional and distal control estimates were 90.3% and 88.3% respectively. Prognosis was significantly superior for cases treated with primary surgery compared to cases solely managed with non-surgical modalities. Positive surgical margins and regional disease worsened prognosis.

Conclusion

This study suggests that primary surgery remains a key element in the treatment of advanced laryngeal cancer. The need for well-designed, prospective, randomised studies in order to further evaluate the remaining role of primary surgery in the modern management of locally advanced laryngeal lesions is emphasized.

Frozen margin analysis as a prognosis predictor in early glottic cancer by laser cordectomy

OBJECTIVES/HYPOTHESIS

The impact of margin status on the outcomes of early glottic cancer after endoscopic resection is controversial; second look laryngoscopy has shown a low rate of residual cancer, even in margin positive patients. Intraoperative frozen section analysis has been suggested as an alternative to routine second look procedures. The aim of this study was to evaluate and search for predictors of outcomes in patients following endoscopic resection based on intraoperative frozen section margin analysis.

STUDY DESIGN

Retrospective chart review.

METHODS

Records of consecutive patients treated for early glottic cancer by endoscopic resection with the CO2 laser were evaluated for margin status at the time of intervention, disease recurrence rate, and survival data. Kaplan-Meir survival rates were determined and subgroups were compared with log-rank test and Chi-square test.

RESULTS

From February 2004 to September 2011, 75 consecutive patients with complete records were identified. The 5-year overall survival rate and the disease-specific survival rate are 84 and 98%, respectively. Recurrence within 12 months (P = 0.019) and initially positive frozen section margins, despite enlarging the cordectomy field to obtain negative margins (P = 0.001), were determined to be predictors for poor overall survival.

CONCLUSIONS

In endoscopic resection of early glottic cancer with the CO2 laser, initial intraoperative frozen section margin involvement during the primary resection and early local recurrence are poor signs for overall survival.

LEVEL OF EVIDENCE

4.

Primary surgical treatment of T3 glottic carcinoma: long-term results and decision-making aspects

OBJECTIVES/HYPOTHESIS

The aim of this study was to assess the efficacy of primary surgical treatment in the management of T3 glottic carcinomas.

STUDY DESIGN

Retrospective clinical study.

METHODS

A retrospective evaluation of the records for all patients treated with primary surgery for T3 glottic carcinomas at a tertiary referral center between 1980 and 2005 was carried out. Data for the 5-year disease-specific survival (DSS) were assessed, as well as local control rates in relation to vocal cord immobility, N classification, choice of surgical modality, and adjuvant therapy. Patients who underwent partial laryngectomy were also evaluated in relation to organ preservation and the rate of permanent tracheotomies.

RESULTS

The 5-year DSS in the 120 patients was 78.3%. Positive neck disease was shown to be a significant negative prognostic factor. Organ preservation was achieved in 90.1% of the patients who underwent partial laryngectomy and in 50% of the overall patient group. The occult metastasis rate was 14%.

CONCLUSIONS

Primary surgical treatment is an effective modality against T3 glottic carcinomas. Partial laryngectomy is a reliable method in carefully selected cases. Low complication rates can be expected.

Identification and validation of gene expression models that predict clinical outcome in patients with early-stage laryngeal cancer

BACKGROUND

Despite improvement in therapeutic techniques, patients with early-stage laryngeal cancer still recur after treatment. Gene expression prognostic models could suggest which of these patients would be more appropriate for testing adjuvant strategies.

MATERIALS AND METHODS

Expression profiling using whole-genome DASL arrays was carried out on 56 formalin-fixed paraffin-embedded tumor samples of patients with early-stage laryngeal cancer. We split the samples into a training and a validation set. Using the supervised principal components survival analysis in the first cohort, we identified gene expression profiles that predict the risk of recurrence. These profiles were then validated in an independent cohort.

RESULTS

Gene models comprising different number of genes identified a subgroup of patients who were at high risk of recurrence. Of these, the best prognostic model distinguished between a high- and a low-risk group (log-rank P<0.005). The prognostic value of this model was reproduced in the validation cohort (median disease-free survival: 38 versus 161 months, log-rank P=0.018), hazard ratio=5.19 (95% confidence interval 1.14-23.57, P<0.05).

CONCLUSIONS

We have identified gene expression prognostic models that can refine the estimation of a patient's risk of recurrence. These findings, if further validated, should aid in patient stratification for testing adjuvant treatment strategies.

Molecular pathways of lymphangiogenesis and lymph node metastasis in head and neck cancer

Metastasis to regional lymph nodes constitutes the main route toward progression and dissemination of head and neck carcinoma; at the same time it is the most significant adverse prognostic indicator for this disease. In recent years, significant focus has been given on the molecular mechanisms behind lymph node metastasis of head and neck cancer. The aim of this study is to assess the role of growth factor expression and function in association with lymph node metastasis and overall prognosis of head and neck cancer. Current literature, searching for experimental data regarding the molecular pathways of lymph node dissemination of head and neck cancer, is reviewed giving special emphasis on the expression and prognostic significance of specific growth factors. Members of the vascular endothelial growth factor (VEGF), mostly VEGF-C and VEGF-D, with their action through the receptors VEGFR-3 and VEGFR-2, constitute the most extensively studied growth factors associated with lymphangiogenesis so far. High expression of these as well as other molecules, including angiopoietins, insulin-like growth factor, and fibroblast growth factor, has been associated with lymph node metastasis and poor prognosis in head and neck squamous cell carcinoma. Numerous growth factors seem to play an important role regarding the lymph node metastatic potential of head and neck cancer. Further research is necessary in order to further clarify the molecular pathways and introduce novel therapeutic options.