声门上型喉癌的CO2激光治疗

声门上型喉癌的经口CO₂激光手术(TSL)是经口腔径路于显微镜辅助下使用CO₂激光切除肿瘤,具有损伤小、并发症少、术后恢复快等优点。该术式已逐渐成为T1、T2声门上型喉癌的治疗方法之一,现就TSL的发展史及手术过程作一阐述。     

Impact of anterior commissure involvement on local control of early glottic carcinoma treated by laser microresection

OBJECTIVES: To analyze the impact of anterior commissure involvement on local control, survival, and laryngeal preservation in patients with early glottic cancer (pT1a-pT2a) treated with unimodality laser microsurgical resection. STUDY DESIGN: Retrospective review of 263 patients with early glottic cancer treated between 1986 and 1996. METHODS: Data on local control and overall survival rates were analyzed and calculated by the Kaplan-Meier method; the larynx preservation rates were given absolutely. RESULTS: Among 158 patients presenting with T1a glottic cancer, the anterior commissure was involved in 28 cases; the 5-year local control rate was 84%, and the larynx preservation rate was 93%. In the 130 cases without anterior commissure involvement, the 5-year local control rate was 90.0% and the corresponding larynx preservation rate 99%. In the T1b category consisting of 30 patients, anterior commissure involvement was observed in 16 patients; the 5-year local control rate was 73%, and the larynx preservation rate was 88%. In the 14 cases without anterior commissure involvement, the 5-year local control rate was 92% and the corresponding larynx preservation rate 100%. Seventy-five patients had T2a glottic carcinomas, with normal vocal cord movement. The anterior commissure was involved in 45 cases; the 5-year local control rate was 79%, and the larynx preservation rate was 93%. In the 30 cases without anterior commissure involvement, the 5-year local control rate was 74.0% and the corresponding larynx preservation rate 97%. CONCLUSIONS: This study shows the effectiveness of laser microsurgery for early glottic carcinoma regardless of anterior commissure involvement at presentation. This method can be performed as an outpatient procedure, even when conducting reresections.     

Treatment of laryngeal carcinomas by laser endoscopic microsurgery

OBJECTIVES: To determine if laser endoscopic microsurgery is a reliable and appropriate approach in the treatment of laryngeal cancers. STUDY DESIGN: Retrospective study of 160 patients treated from 1988 to 1996 at Liège. Analysis of indication, technique, and oncologic results. METHODS: Glottic tumors were treated with either type I, type II, or type III cordectomy, with or without conservation of an inferior muscular band, and extended if necessary to all or part of the contralateral cord. For supraglottic cancers, an excision limited to a part of the vestibule, a trans-preepiglottic resection, or a radical supraglottic resection was carried out. RESULTS: Our corrected actuarial survival at 5 years was 97% for the 98 infiltrative glottic tumors and 100% for the 18 infiltrative supraglottic and 27 in situ carcinomas. No local recurrences were noted, in either the group of 118 infiltrating cancers (in whom two precancerous lesions were treated with a further laser excision), or in the 27 in situ carcinomas. Local control was thus 100%. One patient died of his cancer, with lung metastases after neck recurrence. CONCLUSIONS: Like Steiner and Rudert, this series demonstrates the oncologic validity of this surgical approach to the treatment of unadvanced glottic tumors. Unlike these authors' study, however, strict case selection, as in cases with significant involvement of the anterior commissure, has allowed us to avoid local recurrences and consequently to avoid salvage total laryngectomies. Our experience with supraglottic cancers is too small to confirm the oncologic validity of this type of surgery but seems promising.     

Repeated transoral laser microsurgery for early and advanced recurrence of early glottic cancer after primary laser resection

Objectives

To analyze the oncological results of repeated transoral laser microresection (TLM) in case of failure after primary laser resection of early glottic cancer (pTis-pT2).

Methods

Fifty-six patients with local or loco-regional recurrence of early glottic cancer were treated between 1988 and 2005 by repeated TLM followed, if necessary, by neck dissection and/or adjuvant radio- or radiochemotherapy. Data on overall survival, disease-specific survival, and loco-regional control rates were analyzed retrospectively and calculated by the Kaplan–Meier method.

Results

Forty-four patients (78.6%) presented with early local recurrence (rTis-rT2N0; Stage I/II) and 12 patients (21.4%) had advanced local or loco-regional recurrence (pT3 and pT4N0/N+; Stage III/IV). Three- and five-year overall survival rates for patients with early and advanced recurrence were 75.1% vs. 51.6% and 61.6% vs. 25.8%, respectively. The corresponding three- and five-year disease-specific survival rates were 87.2% vs. 85.7% and 81.0% vs. 85.7%, respectively. Three- and five-year loco-regional control was significantly higher for patients treated for early recurrence (67.6% vs. 27.5% and 63.6% vs. 27.5%, respectively; p = 0.02). Salvage laryngectomy rates for patients with early and advanced recurrence were 9.1 and 25.0%, respectively. In patients with early local recurrence, anterior commissure involvement (n = 11) did not affect the oncological results.

Conclusions

In case of early local recurrence after primary TLM of early glottic cancer, further TLM seems to be justified as an organ-preserving treatment option. In contrast, salvage laryngectomy should be considered early for patients with advanced local or loco-regional recurrence.     

Transoral laser microsurgery for recurrence after primary radiotherapy of early glottic cancer

Objective

To analyze oncological results of transoral laser microsurgery (TLM) on recurrent early glottic cancer after primary radiotherapy.

Methods

The records of 53 patients treated by TLM for early (rTis–rT2) and advanced (rT3, rT4) recurrence after curative radiotherapy were retrospectively analyzed. Data on loco-regional control, overall survival, and disease specific survival were calculated by the Kaplan–Meier method. The larynx preservation rates were given absolutely.

Results

Mean post-therapeutic follow-up time after TLM for patients alive was 87.9 months. Twenty-two patients (42%) were cured by the first TLM procedure, but one of them underwent total laryngectomy after TLM due to chondronecrosis without evidence of residual tumor. Thirty-one patients (58%) developed another recurrence after TLM. Ten of them were cured by further laser procedures alone. Therefore, in 31 patients (58%), local recurrences were successfully treated by TLM alone. In 20 patients, recurrences could not be controlled by TLM: 14 patients underwent salvage laryngectomy and six palliative treatment. Three- and five-year loco-regional control rates for all patients were 46.1 and 38.8%. Three- and five-year overall survival rates were 67.5 and 53.3%. The corresponding 3- and 5-year disease specific survival rates were 68.6%, each. There was no statistically significant difference in loco-regional control or survival between patients presenting initially with early and advanced recurrence. Further recurrence after the first TLM procedure was associated with a statistically significant decrease in 3- and 5-year overall (56.6% vs. 81.8% and 40.2% vs. 70.5%; p = 0.03) and disease specific (48.9% vs. 100%, each; p = 0.001) survival. Ultimate local control rate including repeated TLM and salvage laryngectomy was 77.4%.

Conclusions

Many patients with recurrent glottic carcinoma after primary radiotherapy can be cured by single or repeated TLM as an organ-preserving procedure. However, in case of failure after TLM for the first recurrence, salvage laryngectomy should be considered early as local control by further laser surgery is unfavorable.     

CO2激光联合低温等离子治疗早期声门型喉癌40例

目的 探讨CO₂激光联合低温等离子治疗早期声门型喉癌(EGC)的临床疗效。 方法 回顾性分析内镜下CO₂激光联合低温等离子治疗的40例EGC患者的临床资料,观察术后治疗效果及复发情况。 结果 所有患者首次手术均为内镜下CO₂激光联合低温等离子切除术,共随访4.2~32.0个月(平均18.6个月)。40例均未失访,复发1次3例,复发2次2例,复发率12.5%。复发后行喉全切除术2例,复发后行喉垂直部分切除术1例,复发后行颈淋巴结清扫术1例,复发后再行CO₂激光联合低温等离子切除术+气管切开术1例。 其中喉全切除再次复发行放、化疗及介入治疗,治疗效果差1例;喉垂直部分切除再次复发后选择放疗1例,治疗情况欠佳;余3例末次手术后恢复良好。术后肉芽组织增生9例,术后出现声带粘连4例。36例患者术后发音功能恢复满意,恢复欠佳2例,复发行喉全切除术后丧失发音功能2例。 结论 内镜下CO₂激光联合低温等离子治疗EGC可弥补激光和低温等离子单一治疗模式的不足、提高手术效率,临床有效可行。     

CO2激光显微手术在喉癌前病变和早期声门型喉癌中的应用

目的 探讨CO₂激光显微手术在喉癌前病变和早期声门型喉癌治疗中的应用价值。 方法 选取南京医科大学附属南京医院耳鼻咽喉科自2014年1月~2018年8月期间收治的27例行CO₂激光显微手术治疗的喉癌前病变(9例)和早期声门型喉癌(18例)作为研究对象,观察术后并发症、对比手术前后的生活质量及术后1~2年局部的复发率,探讨其应用价值。 结果 根据CO₂激光显微手术切除的范围和深度进行手术:9例癌前病变中8例行I型手术、1例行Ⅱ型手术;18例早期声门型喉癌中3例行Ⅱ型手术、11例行Ⅲ型手术、3例行Ⅳ型手术、1例行Ⅴ型手术。1例因切缘阳性改行开放式手术,其余患者均未行气管切开,亦无气道烧伤等严重并发症。患者术后6 h软食,均无呛咳、呼吸困难等不良反应,术后抗感染抗炎治疗2~3 d。术后随访1~2年,嗓音恢复可。 结论 CO₂激光显微手术治疗喉癌前病变和早期声门型喉癌临床效果显著、安全性较高、创伤小、术后嗓音恢复快、住院时间缩短、并能较为理想的保留喉功能、提高患者术后的生活质量。     

Prognostic significance of surgical margins in transoral CO<Subscript>2</Subscript> 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.     

Organ preserving transoral laser microsurgery for cancer of the hypopharynx

OBJECTIVE: To assess the feasibility of transoral laser microsurgery (TLM) in the treatment of hypopharyngeal cancer, with a special focus on piriform sinus carcinomas, and to report the oncologic and functional outcomes. STUDY DESIGN: Prospective case-series study at a single institute, an academic tertiary referral center. METHODS: A total of 172 patients with previously untreated squamous cell carcinoma of the hypopharynx were eligible for this study (1986-2003). The piriform sinus was the most common localization (n = 150). Patients with simultaneous second primaries, distant metastases, or N3 neck disease and cancers of the category pT4b were excluded. Fifteen percent of the patients had stages I and II (according to guidelines from the Union Internationale Contre le Cancer 2002/American Joint Commission on Cancer, 2002), and 85% had stages III and IVa. The median follow-up period was 45 months. All patients (n = 172) were treated by TLM, mainly by selective neck dissection (93%) and/or postoperative radiotherapy (52%). Overall survival, recurrence-free survival, organ preservation, and local control were analyzed as end points. Rate of tracheotomies, postoperative complications, and swallowing function (feeding tube dependency) were also analyzed. RESULTS:: Five-year Kaplan-Meier local control was 84% for pT1; 70% for pT2; 75% for pT3; and 57% for pT4a. Five-year Kaplan-Meier recurrence-free survival was 73% for stages I and II, 59% for stage III, and 47% for stage IVa. The whole group of 172 hypopharyngeal cancer patients was analyzed, with an additional special focus on the homogenous group of piriform sinus carcinomas (n = 150). CONCLUSIONS: Our data support the conclusion that TLM is a valid option to standard radical surgery or standard conservation treatment. Oncologic and functional results compare favorably, while morbidity and complication rates tend to be lower.     

Oncologic and functional outcomes of transoral CO2 laser cordectomy for early glottic cancer

ObjectiveTo investigate the oncological and functional outcomes of the patients treated with transoral CO2 laser cordectomy for early glottic cancer.Patients and methodsFifty-five consecutive patients who underwent CO2 laser cordectomy for early glottic cancer were retrospectively reviewed.ResultsOverall survival, larynx preservation, and relapse free local control rates were 96%, 100%, and 91%, respectively. Five patients with local recurrences were salvaged with re-cordectomy and/or radiotherapy. In type I cordectomy, VHI-10 consistently improved during postoperative course and VHI-10 at postoperative 12 months was significantly better than preoperative value (2.3 vs. 9.4, p = 0.02). Perceptual grading, MPT, MFR and AC/DC also improved and were better than preoperative values. In type III cordectomy, shimmer at 12 months after cordectomy was significantly better than preoperative value (14.7 vs. 9.3, p = 0.007).ConclusionsThese results further support the rationale of CO2 cordectomy as initial and salvage surgery for early glottic cancer.     

CO2激光显微手术与传统显微手术切除声带息肉疗效比较

目的 比较显微镜CO₂激光机下与传统显微镜支撑喉镜下切除声带息肉的疗效及恢复情况。 方法 选择2013年5月至2016年9月就诊的214例声带息肉患者,按照病理情况和治疗方法不同分为四组,分别为普通CO₂激光组50例,普通传统显微镜组56例,复杂CO₂激光组48例,复杂传统显微镜组60例,比较两种手术方法治疗不同病理情况患者的嗓音疗效。 结果 四组患者总体疗效比较,差异无统计学意义(P > 0.05)。术后普通型和复杂型声带息肉患者通过两种手术方式治疗总有效率、基频、基频微扰、振幅微扰、噪声能量、谐噪比比较均无统计学差异(P > 0.05)。 结论 显微镜CO₂激光手术与传统显微镜支持喉镜手术治疗声带息肉均能取得较为满意效果,需根据患者具体病情选择最佳治疗方案、优化手术及术后恢复。     

Carcinoma of the tongue base treated by transoral laser microsurgery, part one: Untreated tumors, a prospective analysis of oncologic and functional outcomes

OBJECTIVES: To report the oncologic and functional outcomes of transoral laser microsurgery (TLM) in the management of untreated primary carcinoma of the tongue base. STUDY DESIGN: A two center prospective case series analysis. METHODS: Fifty-nine patients with pathologically confirmed squamous cell carcinoma of the tongue base were treated with TLM between 1997 and 2005. The pathological T stage distribution was: T1, 16; T2, 23; T3, 12 and T4, 8. Thirty-six patients presented with stage IV disease, 12 with stage III, 7 with stage II and 4 with stage I disease. Neck dissections were performed in 49 patients (83%). Twenty-eight patients (47%) underwent adjuvant radiotherapy. End points analyzed were local control, loco regional control, disease specific survival, and overall survival. Organ function was assessed before and after treatment using a clinical Functional Outcome Swallowing Scale (FOSS) and Communication Scale (CS) staging system. RESULTS: The mean follow up for all patients was 31 months. The 2 and 5-year Kaplan-Meier estimates were: local control, both 90%; loco-regional control, both 88%; recurrence free survival, both 84% and overall survival 91% and 69% respectively. For all patients the median stay in hospital was 4 days. The median length of hospital visit for TLM alone was 2.5 days and 4 days for TLM with neck dissection. Three patients (5%) suffered minor post-operative hemorrhage. The median pre-operative FOSS stage was 0 (normal function.) The median post-operative FOSS stage was stage 1 (Normal function with episodic or daily symptoms of dysphagia.) There were no clinically significant changes in communication function after treatment. CONCLUSIONS: Transoral laser surgery is a safe and effective treatment for select early and advanced previously untreated squamous cell cancer of the tongue base. In addition, the low morbidity and mortality and shortened duration of hospitalization associated with TLM make it an attractive therapeutic alternative.     

Carcinoma of the tongue base treated by transoral laser microsurgery, part two: Persistent, recurrent and second primary tumors

OBJECTIVES: To report the oncologic and functional outcomes of transoral laser microsurgery (TLM) in the treatment of persistent, recurrent, and second primary squamous cell carcinoma of the tongue base. STUDY DESIGN: A two-center prospective case series analysis. METHODS: Twenty-five patients with persistent, recurrent, or second primary squamous cell carcinoma of the tongue base were treated with TLM between 1997 and 2005. Four (16%) patients with persistent disease at the primary site were considered TX. Eleven (44%) patients with recurrent disease were pathologically staged rT1 3/11, rT2 2/11, rT3 4/11, T4 1/11, and TX 1/11. Ten (40%) patients with second primary tumors were staged pT1, 4/10; pT2, 3/10; pT3, 2/10; and pT4, 1/10. Eight (32%) patients underwent neck dissection. Three (12%) patients received adjuvant radiotherapy. Pre- and post-treatment organ function was assessed using a clinical Functional Outcome Swallowing Scale (FOSS) and Communication Scale. RESULTS: The mean follow-up period was 26 months. The 2-year Kaplan-Meier local control and locoregional control estimate was 69%. For those patients presenting with persistent/recurrent or second primary disease, the 2 year local control estimates were 75% and 68%, respectively. For all patients, the respective 2 and 5 year overall survival estimates were 54% and 26%. Two (8%) patients suffered postoperative hemorrhage. The average duration of hospitalization was 3.6 days. The median pretreatment and posttreatment FOSS stage was stage 2 and stage 3, respectively. CONCLUSIONS: Transoral laser surgery is a rational and effective treatment in appropriately selected patients with persistent, recurrent, or second primary tongue base cancer. The low morbidity and mortality and shortened duration of hospitalization associated with TLM make it an attractive therapeutic alternative.     

Technique of en block laser endoscopic frontolateral laryngectomy for glottic cancer

During the last 30 years, there has been expansion of the role of endoscopic partial laryngectomy procedures since Jako, Strong, and Vaughan explored the possibilities of CO2 laser microlaryngeal procedures. Despite the fact that a number of investigators have verified the validity of endolaryngeal laser resection of mid-sized glottic cancer, there are many who are unfamiliar with the technique and others who are uncomfortable with sectioning the tumor to facilitate its resection. In the past 3 years, 15 patients underwent successful en block resection of mid-sized glottic cancer (T1b 2, T2b 11, T3 2). Because en block resection is more consistent with open oncologic approaches, this method should widen the acceptance of this approach in selected lesions. The nuances of en block endoscopic frontolateral laryngectomy are presented with the hope that more surgeons will adopt this philosophy as an aspect of their armamentarium.     

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

IntroductionTransoral 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.ObjectiveThe 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.MethodsWe 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.ResultsFive-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.ConclusionThis 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.