The utility of second look microlaryngoscopy after trans oral laser resection of laryngeal cancer

Impact of resection margin status and revision transoral laser microsurgery in early glottic cancer: analysis of organ preservation and local disease control on a cohort of 153 patients

Introduction

Transoral laser microsurgery represents the treatment of choice for early glottic cancer. Its use and effectiveness are mainly related to laryngeal exposure and deep extension of tumor. Histopathologic assessment of surgical margin presents a main issue about transoral laser microsurgery and complete oncological excision.

Objective

The aim was to analyze the impact of revision surgery on organ preservation and local disease control in patients with early glottic cancer treated by transoral laser microsurgery.

Methods

We carried out a retrospective study on a cohort of 153 patients with early glottic cancer (Tis, T1, T2) treated by transoral laser microsurgery. Resection margins were classified as follows: “free” if macroscopic margin-tumor distance was at least 2 mm, as “close” if it was less than 2 mm and “positive” if the margin was involved by carcinoma. Patients were divided into two groups: patients with free resection margins (Group A) and patients with positive, close or not-evaluable resection margins (Group B). Group A (36) underwent periodic followup. Group B (117) underwent a second look laser CO₂ 2 months after surgery. Fifteen patients of Group A with suspected persistence of carcinoma during followup underwent a second laser resection after a time interval of 4–8 months after first surgery. Overall survival, disease-free survival, disease-specific survival, ultimate local control with laser alone and organ preservation rates were estimated.

Results

Five-year overall survival rate and 5-year disease-specific survival were 100% in both groups. The five-year laryngeal preservation rate was 100% in Group A and 95.2% in Group B. Five-year disease-free survival was 92.15% and 5-year ultimate local control with laser alone in 92.15% of patients.

Conclusion

This study has demonstrated that revision Transoral Laser Microsurgery is able to confirm the oncological radicality in most cases, even in the case of positive, close or non-evaluable margins. Considering our results, according to our experience, the second look with CO₂ laser is a therapeutic strategy to consider, even in the case of close or non-evaluable as well as positive margins.

Management of Early Glottic Cancer Treated by CO2 Laser According to Surgical-Margin Status: A Systematic Review of the Literature

Introduction  Transoral laser microsurgery (TLM) is the treatment of choice for Tis-T2 squamous cell glottic carcinomas due to its advantages compared with open surgery and radiotherapy. However, the CO ₂ laser beam causes changes and damage on the specimens, making the histological assessment of resection margins, the gold standard for confirming radical tumor resection, sometimes difficult.

Objective  To assess the different ways to manage patients depending on the status of the histopathological margin according to recent studies to detect the most commonly shared therapeutic strategy.

Data Synthesis  We analyzed the literature available on the PubMed and Web of Science databases, including only articles published since 2005, using specific keywords to retrieve articles whose titles and abstracts were read and analyzed independently by two authors to detect relevant studies. Therefore, we focused on disease-free survival, overall survival, local control, laryngeal preservation, and disease-specific survival. Thus, 17 studies were included in the present review; they were grouped according to the status of the histological margin, and we analyzed the different management policies described in them. This analysis showed that there is not a shared strategy, though in most studies the authors performed a second-look surgery in the cases of positive margins and a close follow-up in cases of negative ones. The main disagreement is regarding the management of close or non-valuable resection margins, since some some authors performed a second-look surgery, and others, a close follow-up.

Conclusions  Definitely, the most shared policy is the second-look surgery in case of positive surgical margins, and a close follow-up in case of close or non-valuable resection margins.

Key Points