Transoral Laser Resection for Early Glottic Cancer

The final local control with the laser alone was 100% for patients with initially positive margins, 95% for those with initially suspicious margins and 94% for those with free margins. Organ preservation was 100% for patients with positive or suspicious margins and 96% for those with free margins.

Margin status (p = 0.39), cordectomy type (p = 0.67), and anterior commissure involvement (p = 0.16) were not statistically related to recurrence; however, the recurrence rate was significantly higher for pT1b tumors (p = 0.001).

A second look procedure was performed less than one month following the initial surgery in three cases of suspicious margins. The excisional biopsies performed during the second procedure were all negative, confirming a negative margin status. None of these patients had local recurrence.

Analysis and Recommendations

In light of our experience, we believe that the pathologist’s evaluation of resection margins should be interpreted according to the surgeon’s intraoperative impression of the quality of the resection, said Dr. Hartl. If there is any discrepancy between the surgeon’s impressions and the pathologist’s report, then a ‘second look’ procedure with excisional biopsies should be performed. Another option is a close follow-up with fiberoptic laryngoscopy.

We tend to follow patients with suspicious resection margins every month in our clinic, continued Dr. Hartl. There is no evidence from our study or from the literature that adjuvant radiation therapy is indicated in the case of positive margins and even less evidence for patients with suspicious margins.

Based on our results, we believe that transoral laser microresection is a reliable treatment with high local control and laryngeal preservation for early glottic cancer, Dr. Hartl said. Positive or suspicious margins were not related to the rate of recurrence, nor was anterior commissure involvement. Suspicious margins can be managed with a ‘watch and wait’ attitude and retreatment using the laser; external partial laryngectomy or radiation therapy remain therapeutic options for laryngeal preservation in case of local recurrence or metachronous primary malignancy.

United Healthcare’s Deadline Extended

Citing constructive and collegial feedback from physicians in our network, United Healthcare has extended its March 1 deadline for facility imaging accreditation until the third quarter of this year (see To Accredit or Not to Accredit? ENT Today, February 2008, p. 8). No specific date in the third quarter has yet been established.

The accreditation initiative, which United Healthcare has undertaken in conjunction with the American College of Radiology and the Intersocietal Accreditation Commission, aims to bring equipment (including CT, MRI, PET, and other imaging equipment), technologists, physicians, and facilities into compliance with uniform performance standards. Physicians who are part of the UHC network will be required to have obtained accreditation as a condition for reimbursement for these imaging procedures. For more information about the accreditation programs, go to www.acr.org or www.intersocietal.org .

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