Positive surgical margins in cancer of the larynx

Comparative Survival Function in Patients with Positive Surgical Margins Following Laryngectomy

Aims: This study aims to make a comparative analysis of disease-free survival (DFS) and overall disease-specific survival (OS) in patients with laryngeal carcinoma. Materials and methods: The study was designed retrospectively. Sixteen patients with postoperative PSM and 30 with negative surgical margins (NSM) were included. Survival analysis and Long-Rank comparisons was performed for DFS and OS between groups. Results: PSM was a significant independent risk factor for loco-regional recurrence and disease-related mortality (p = 0.004, HR: 1.6, p = 0.002, HR: 3.2, respectively). DFS and OS were significantly longer in NSM group (p = 0.001 and 0.003, respectively). For PSM group, 2- and 5-year DFS rates were 57%; OS rates were 80% and 34% respectively. In NSM group, 2- and 5-year DFS rates were 96% and 83%; OS rates were found to be 96%. Conclusion: PSM had significant relation with poor prognosis.

Frozen Section Evaluation for Surgical Margins in Laryngeal Squamous Cell Carcinoma: Is it a Reliable Method for Partial and Total Laryngectomies?

BACKGROUND

In this study, we aimed to compare the accuracy of frozen section evaluation in partial and total laryngectomies performed to treat laryngeal squamous cell carcinoma .

METHODS

A retrospective study was conducted to evaluate the efficacy and accuracy of frozen section analysis for laryngeal squamous cell carcinoma of 65 patients, operated at a tertiary hospital. Two groups were recruited according to the surgical procedure.

RESULTS

The sensitivity and specificity of frozen section diagnosis in laryngeal cancer were 20% and 99.73%, respectively. For partial laryngectomy, the sensitivity was 16.66% and specificity was 100%. For total laryngectomy, sensitivity was 22.2% and specificity 99.13%. Discordances between the initial frozen section diagnosis and the subsequent permanent section diagnosis were found in 13 (3.35%) pairs (3.37% partial laryngectomy and 3.33% total laryngectomy).

CONCLUSION

Our study shows that the surgical method applied has no effect on discordances. However, sampling errors are likely to be more common in partial laryngectomy procedures. It should be kept in mind that the sensitivity of frozen section evaluation is low.

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.

The effect of midline crossing of lateral supraglottic cancer on contralateral cervical lymph node metastasis

CONCLUSION

The degree of midline crossing of lateral supraglottic cancer does not significantly change its rate of contralateral cervical metastasis. The rate of occult metastasis is too high to take the risk of contralateral regional recurrence. We support routine bilateral neck dissection even in lateral supraglottic cancers with no or minimal midline crossing.

OBJECTIVES

Data on the rate of contralateral cervical metastasis of laterally located supraglottic cancer, the effect of its degree of midline crossing on contralateral cervical metastasis, and its treatment are still controversial.

METHODS

This was a retrospective cohort, chart review involving 305 surgically treated patients with T1-3 squamous cell carcinoma of the supraglottic larynx. In all, 184 patients had bilateral neck dissection; 86 N0 contralateral necks were followed up. Thirty-five patients who needed postoperative radiation therapy because of the primary tumor or ipsilateral neck dissection specimen also received radiation therapy to the contralateral neck. The degree of midline crossing at the epiglottis was measured on a laryngectomy specimen with a ruler and expressed as 'no,' '<5 mm' or '≥5 mm.'

RESULTS

The rates of occult and overall contralateral metastasis in our series were 16% and 28%, respectively. There was no statistically significant difference between contralateral neck metastasis and recurrence rates in the neck dissection, follow-up, and irradiation groups according to the degree of midline crossing.

Effect of repeated laser microsurgical operations on laryngeal cancer prognosis

BACKGROUND

The aim of this study was to evaluate whether repeated sessions of transoral CO(2) laser microsurgery (TLM) aiming to achieve clear histologic margins carry a negative effect on the prognosis of laryngeal cancer.

METHODS

This was a retrospective evaluation of 763 cases that underwent primary TLM treatment for laryngeal cancer. Cases were compared for overall survival and local control rates with respect to status of surgical margins and number of procedures necessary to achieve these margins.

RESULTS

No significant differences were noted among cases with negative surgical margins regardless of the number of procedures necessary to achieve these margins. On the other hand, positive margins at the end of surgical treatment carried significant negative prognostic effect.

CONCLUSION

The prognostic effect of negative surgical margins in TLM for laryngeal cancer is significant regardless of the number of procedures required to obtain such margins.

Resection margins and other prognostic factors regarding surgically treated glottic carcinomas

BACKGROUND AND OBJECTIVES

This study aims to assess the prognostic significance of free histopathologic margins in the surgical treatment of glottic cancer. Furthermore, it evaluates other prognostic factors regarding cases that receive surgical management for glottic lesions.

METHODS

A retrospective case-series study was conducted at an academic tertiary referral center. The files of 1,314 cases that underwent primary surgical treatment for glottic cancer were studied. Various prognostic factors, including age, surgical procedure, T classification, N classification, histological grade, and status of margins were assessed in univariate and multivariate analyses. All variables were investigated for their association with local and regional disease control as well as disease specific and overall survival.

RESULTS

Status of margins significantly affected disease specific survival and local control regardless of tumor stage in this series. All other variables assessed in the univariate analysis for their association with survival were also found to be significant. However, status of surgical margins and N classification were the only significant variables in multivariate analysis.

CONCLUSION

The prognostic value of negative surgical margins for the treatment of glottic cancer cannot be overestimated. Responsibility of the surgeon during primary surgical treatment of glottic carcinomas is emphasized.

Early outcomes after transoral CO2 laser resection of laryngeal and hypopharyngeal squamous cell carcinoma: one centre's experience

Objectives:

To review early oncological outcomes following transoral CO2 laser resection of laryngeal and hypopharyngeal squamous cell carcinoma.

Design:

Retrospective review of hospital electronic database.

Setting:

Large district general hospital in England, UK.

Main outcome measures:

Patients' three-year disease-specific survival and disease-free survival were evaluated, including post-operative complications, voice quality and swallowing status.

Results:

Seventy-seven patients (16 women and 61 men) were identified. Transoral laser excision of squamous cell carcinoma of the larynx was undergone by 65 patients, and the same procedure in the hypopharynx by 12. Patients with laryngeal cancer had statistically better disease-specific survival than those with hypopharyngeal cancer (p = 0.021), although the cumulative disease-free survival probability was 0.71 for both larynx and hypopharynx groups. Patients who underwent laryngectomy following failed laser treatment or as a salvage procedure had poorer outcomes.

Conclusions:

The overall results of this study were comparable with those of other, larger studies. At three-year follow up, cumulative disease-specific survival probabilities were 0.92 and 0.71 for laryngeal and hypopharyngeal squamous cell carcinoma, respectively.

Prognostic significance of surgical margins in transoral CO2 laser microsurgery for T1–T4 pharyngo-laryngeal cancers

Histological affected or close margin is an adverse factor in conventional surgery of larynx-hypopharynx cancer. Our objective was to analyze the relevance of the margins in transoral laser microsurgery (TLM). A retrospective study of 357 consecutive patients with cancer of the larynx and hypopharynx (T1-T4) treated with TLM. Three possible margins were considered: tumor free, affected, and uncertain. An affected margin showed marked tumor infiltration. An uncertain margin was defined when the sample was insufficient, when it showed carbonization impeding accurate evaluation, or when tumor cells were less than 2 mm. Margins were free in 254 (71.1%) patients, affected in 64 (17.9%) and uncertain in 39 (10.9%). One hundred and three patients (28.9%) presented tumor relapse. The margins were associated with tumor relapse (P < 0.001), but were not significantly related to the tumor site (P = 0.307), the pT classification (P = 0.183), or the difficulty of surgical exposure (P = 0.427). Distant metastases were found in 4.7% of the patients with free margins, in 7.7% of those with uncertain margins, and in 14.1% with affected margins. These differences were statistically significant (P = 0.028). Tumor involvement of the surgical margin was associated with higher rates of local relapse, distant metastasis and the necessity of salvage surgery, together with a lower specific actuarial survival rate.

Endolaryngeal cordectomy using cold instruments for treatment of T1 glottic cancers

In the treatment of early-stage glottic cancers, radiotherapy and surgery have similar success rates. In our department, we have been using cold instruments coupled with surgical microscope and/or telescopes for several years in treatment of early stage glottic cancers. Our aims were, to present our experience with endolaryngeal resection of T1 glottic cancers with cold instruments coupled with surgical microscope and telescopes, to present our oncological results, to discuss the advantages of endolaryngeal cordectomy over open cordectomy or RT and to discuss whether laser is obligatory for this approach or not. Our study includes retrospective analysis of 38 patients with T1 glottic cancer, who have been treated with endolaryngeal surgery as the primary treatment. The median follow-up was 24 months. The most commonly performed procedure was type-II cordectomy (38.5%). Overall survival rate was 94.7%, while the disease-specific survival rate was 100%. Local recurrences occurred in two patients at 8th and 11th months, postoperatively. In the first patient, type-Vc cordectomy and in the second type-Va cordectomy had been performed. Both patients with recurrences could be salvaged by fronto-lateral laryngectomy, and are still alive in their 38th and 6th months following salvage surgery. Therefore, the local control rate and larynx preservation rate with endolaryngeal cordectomy were 94.7 and 100%, respectively, in this study group. All patients had a voice quality sufficient for communicating easily over telephone. We believe that lasers are not obligatory to perform endolaryngeal cordectomy for treatment of T1 glottic cancers, as the same oncological and similar functional outcomes may be achieved with the traditional cold instruments.

Extended and standard supraglottic laryngectomies: a review of 110 patients

The purpose of this study was to compare functional and oncological results of extended and standard supraglottic laryngectomies. One hundred ten patients with supraglottic carcinoma were treated. A standard supraglottic laryngectomy (SSL), a laterally extended supraglottic laryngectomy (LESL) and an anteriorly extended supraglottic laryngectomy (AESL) were performed on 32, 47 and 31 patients, respectively. Indications for postoperative radiotherapy included positive surgical margins (23% of patients) and/or node metastasis (63% of patients). Local recurrence occurred in 13% of SSL, 15% of LESL and 17% of AESL patients. Pulmonary complications due to aspiration were observed in 6% of SSL, 15% of LESL and 19% of AESL. The overall 5-year cure rates were 63% for SSL, 45% for LESL and 47% for the AESL procedures. Extended supraglottic laryngectomies provided as good a local tumor control as SSL. Extension to the hypopharynx (LESL) and to the vallecula (AESL) showed more frequent pulmonary complications and reduced cure rates.

Prognostic Value of Resection Margins in Supracricoid Laryngectomy

OBJECTIVES

The objective was to assess the prognostic value of surgical margin involvement in patients treated for squamous cell carcinoma of the larynx.

STUDY DESIGN

Retrospective study.

METHODS

A review was made of 253 patients treated with supracricoid laryngectomy between 1984 and 2001. A histopathological study on the surgical resection margins was performed in all cases. The incidence of local recurrence was correlated with the histological features of resection margins.

RESULTS

Forty patients (15.8%) were identified as having positive margins: 29 had invasive carcinoma and 11 had dysplastic lesions. The remaining 213 patients (84.2%) had negative margins. Subsequent follow-up showed that 19 of 253 patients developed local recurrence and 3 patients developed regional recurrence. Nine of these patients had positive resection margins (six with invasive carcinoma and three with dysplastic lesions), and 10 had negative resection margins. Overall survival at 3 years was significantly higher for patients without recurrence than for patients with local or regional failure (89.9% vs. 45.5% [P <.05]).

CONCLUSION

According to results of the study, patients with positive resection margins developed local recurrence more frequently than those with clear resection margins (P <.05).