During her presentation at the 2007 Combined Otolaryngology Spring Meeting in San Diego, Dana M. Hartl, MD, PhD, from the Department of Otolaryngology Head and Neck Surgery at the Institut Gustave Roussy in France, described her findings from a retrospective, bi-institutional study designed to review the results of a large series of patients with early glottic squamous cell carcinoma treated with curative intent by transoral laser resection.
Explore This IssueMarch 2008
We also sought to compare these results with the pathological assessment of the resection margins, involvement of the anterior commissure, and the extent of the cordectomy, said Dr. Hartl, whose study was published in the Annals of Otology, Rhinology, and Laryngology.
Since the 1990s, transoral laser resection has become a standard treatment for early glottic cancer and a valid alternative to radiation therapy or external partial laryngectomy in terms of oncologic results. Studies have shown that transoral laser resection provides greater than 90% local control and laryngeal preservation for early glottic cancer.
According to Dr. Hartl, the use of this technique requires specific equipment and instrumentation, adequate exposure of the larynx, and specific surgical training and experience. Pathologists analyzing surgical specimens after laser resection also require training and experience because of the small resection specimens and the peripheral coagulation effect (0.5 mm) of laser on resection margins.
Details of the Study
Of 142 patients, 79 were selected for this study, based on their pT stage, the availability of information regarding resection margins, the absence of adjuvant radiation therapy, and evidence of follow-up for at least two years.
Tumors were classified pTis (n = 21), pT1a (n = 51), or pT1b (n = 7) and were treated by cordectomy types I (23%), II (30%), III (27%), IV (6%), and V (14%), based on the European Laryngological Society’s classifications of endoscopic laser cordectomies. Type I is a subepithelial resection (respecting the vocal ligament). Type II is a subligamental resection. Type III is intramuscular (partial resection of the vocalis muscle). Type IV is a total resection of the vocal fold. Type V is an extended cordectomy with subtypes indicating extension to include the anterior commissure (type Va), the arytenoid cartilage (type Vb), the false vocal fold (type Vc), or the subglottis (type Vd).
Surgeons performed the cordectomies with en bloc resection; pathologists considered the resection margins to be: free (tumor at least 2 mm from the edge of the specimen), positive (tumor at the margin of the specimen), or suspicious (tumor less than 2 mm from the edge of the specimen).
The average follow-up was 56 months. The overall five-year actuarial recurrence-free survival rate was 89%, and the five-year actuarial disease-specific survival rate was 97.3%. Eleven local recurrences occurred; seven were treated by another laser resection, one by radiation therapy, one by supracricoid partial laryngectomy, and two by total laryngectomy.
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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