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。     

CO2 transoral laser microsurgery for early glottic carcinoma with anterior commissure involvement

ObjectiveAnterior commissure (AC) involvement is an unfavorable factor for transoral laser microsurgery (TLM) treatment of early glottic carcinoma (EGC). This study aimed to evaluate the therapeutic efficacy of TLM treatment for EGC with AC involvement.MethodsFrom 2008 to 2017, 177 patients with T1-T2 EGC with AC involvement were retrospectively included and divided into the TLM group (n=115) receiving CO₂ laser TLM and the control group undergoing open surgery (n=62). The survival outcomes, postoperative complications, laryngeal preservation rate, recurrence and the phonological results were compared between groups.ResultThe TLM group had significantly reduced hospital stay, hospitalization costs, and intraoperative blood loss as compared with the control group. The tracheotomy rate was significantly higher in the control group (96.8% vs. 0%). The 5-year overall survival (OS) was 89.6% and 85.5% in the TLM group and control group, respectively. Log-rank test showed no difference in survival rate between the two groups. There was no significant difference in laryngeal preservation rate and overall recurrence rate between groups. In postoperative vocal function evaluation, there were significant differences in the overall grade (G), the roughness (R), the breathiness (B), Voice Handicap Index-10 (VHI-10), Jitter, Shimmer, noise/harmonic ratio (NHR), maximum phonation time (MPT), phonation threshold pressure (PTP) between the two groups.ConclusionFor EGC with AC involvement, TLM has similar survival outcomes with the open surgery, but has better postoperative voice outcomes. Meanwhile, TLM can effectively reduce intraoperative blood loss, hospitalization time, hospitalization costs and postoperative complications.     

早期声带癌的CO2激光微创治疗

目的 探讨CO2激光治疗早期声带癌（T1、T2）的疗效。方法 回顾性分析经CO2激光治疗的26例早期声带癌（T1a期12例、T1b期2例和T2期12例）疗效和手术并发症。结果 术后随访5～15个月,所有患者无严重并发症,发音功能恢复良好,复发3例（复发率11.5%）,再次行CO2激光手术2例,行全喉切除术1例。结论 CO2激光手术具有手术创伤小、并发症少和发音功能保留满意等优点,是早期声带癌理想的治疗方法。     

Comparison between transoral microsurgery by CO2 laser and conventional surgical therapy for T2 glottic carcinoma

BACKGROUND: Transoral CO2 laser excision of early glottic cancer was first introduced in the 1970s. Since then it has become a serious alternative to surgery with conventional instruments. PATIENTS AND METHODS: Between January 1987 and December 1997, 46 patients with T2 N0 M0 glottic carcinoma have been treated by either transoral laser microsurgery or fronto-lateral partial laryngeal resection with curative intention. Long-term results of both methods were compared after analysation of tumor-localization and recurrence-rate. Evaluation parameters were: incidence of local recurrence and incidence of death due to local recurrence. Other aspects of investigation were hospitalisation-time and treatment related patient morbidity. RESULTS: Analysis of the data of our study shows that local recurrences were 5 % lower in cases of laser surgical tumor resection as opposed to conventional surgery (11 % vs. 16 %). If evaluated in accordance to localization of local recurrence in combination with primary tumor localization, results show that all three recurrent tumors in the group of laser resected patients had a primary in the anterior glottic area; two out of the three recurrences following fronto-lateral laryngeal resection were localized in the mid-third of the vocal cord. Hospital-admittance in laser-resected patients was shorter by one day when compared with the group of conventional surgery (10 vs. 11 days). CONCLUSION: T2-Tumors of the anterior glottic area should preferably be approached by conventional surgery (external approach), particularly when endoscopical visualization is difficult. In contrast, T2-tumors of the medial and posterior glottic area should be resected endolaryngeally with the laser.     

CO2 laser cordectomy for early-stage glottic carcinoma: a long-term follow-up of 156 cases

OBJECTIVES: To define when laser resection of early-stage glottic carcinoma is indicated and to compare the results obtained by laser surgery with other therapeutic options. STUDY DESIGN: Retrospective study of 151 patients treated from April 1982 to June 1996 in the Department of Otorhinolaryngology at "La Sapienza" University. We provide analysis of indications, techniques, and oncologic results of this study. METHODS: Glottic tumors were treated with type III, type IV, and type Va cordectomies according to the classification of endoscopic cordectomies proposed by the European Laryngological Society in 2000. RESULTS: The results are summarized as follows: all patients with carcinoma in situ Tis are free of disease with local control rate at 3 years of 100%; 2 died of other causes without evidence of local recurrence with an overall survival rate at 3 years of 83.2%. Of the 117 patients with stage T1a cancer, 110 are free of disease at 3 years with local control rate of 94%; 4 patients died of other causes without evidence of local recurrence with an overall survival rate of 96.5%. Of the 22 patients with stage T1b cancer, 20 are free of disease at 3 years with a local control rate of 91%; 1 patient died of other causes without evidence of local recurrence with an overall survival rate at 3 years of 95.4%. CONCLUSIONS: According to our experience, we can conclude that endoscopic laser surgery is an efficacious and cost-effective treatment for early stage glottic cancer.     

早期声门型喉癌CO2激光手术治疗

目的　总结探讨在支撑显微喉镜下通过CO2激光微创手术治疗早期声门型喉癌的疗效。方法　对2007年1月～2012年12月于福建省立医院耳鼻咽喉头颈外科接受CO2激光手术治疗的91例早期声门型喉癌患者进行回顾性分析。结果　全部患者CO2激光手术后随访25～96个月,2例患者失访（视为死亡）,1例患者于术后81个月死于肺癌,喉功能保留率为96.70%（88/91）;10例患者出现局部复发,复发率为11.00%（10/91）,T1a复发率为12.12%（4/33）,T1b复发率为9.10%（3/33）,T2复发率为20.00%（3/15）,组间差异无统计学意义（χ 2=2.645,P >0.05）。前连合受累患者的复发率为28.57%（6/21）,前连合未受累的患者复发率为5.71%（4/70）,两组比较差异有统计学意义（χ 2=8.628,P＜0.05）。5年整体生存率为93.20%,局部区域（喉+颈部淋巴结）5年控制率（无肿瘤复发和转移的比率）86.70%。结论　支撑喉镜下CO2激光治疗早期声门型喉癌的疗效可靠,创伤小,喉功能保全好,恢复快,并发症少,值得临床推广应用。     

CO2激光微创手术治疗早期喉癌

目的观察CO2激光微创手术治疗早期喉癌的安全性、远期疗效。方法回顾性分析1999年10月至2007年5月接受CO2激光显微外科手术治疗91例声门型喉癌（Tis9例，pTla 45例，pTlb 25例，和PT2 12例），对其中20例患者术后创面前、后、中上、中下及深部切缘组织同时进行常规病理切片镜检及PCNA免疫组织化学测定。结果依照Kaplan—Meier方法计算5年整体生存率为92．72％，无瘤生存率84．62％。采用3mm安全界100个切缘标本中，发现癌细胞残留3个（2名患者）。结论早期喉癌CO2激光微创手术，不仅损伤小，愈合快，而且远期疗效好，采用3mm安全界可获得安全切缘。     

CO2激光治疗早期声门型喉癌疗效分析

目的总结CO2激光手术治疗声门型喉癌的临床治疗效果。方法对2002年4月－2007年5月安徽省立医院耳鼻咽喉头颈外科激光手术治疗8961例声门型喉癌进行临床分析。61例中,T1a33例,T1b16例,T212例。累及前联合者12例,未累及前联合者49例。术后随诊12～73个月。结果61例支撑喉镜下C02激光手术后5例局部复发,1例T2患者术后7个月出现同侧颈淋巴结转移,局部（区域）复发率为9．8％（6／61）。T1a复发率3．0％（1／33）,T1b复发12．5％（2／16）,T2复发率25．0％（3／12）,组间差异有显著性（Χ^2=4．836,P〈0．05）。病变侵犯前联合复发率16.7％（2／12）,病变未侵犯前联合复发率8．2％（4／49）,两组间差异无显著性（Χ^2=0．697,P〉0．05）。61例激光手术治疗的患者,58例存活,死亡3例。结论激光手术治疗早期声门型喉癌疗效可靠,喉功能保全好,是早期喉癌理想的治疗方式。     

Conservative laser microsurgery for T1 glottic carcinoma

OBJECTIVE: The purpose of the study was to assess whether partial cordectomy or complete cordectomy with narrow free margins is a safe oncological procedure for T1 glottic carcinoma. We also studied surgical margins and the involvement of anterior commissure. METHODS: Thirty-one T1 glottic carcinomas underwent endoscopic CO(2) laser excision of the lesion based on the depth of infiltration by the tumor with 1-2mm free margins. If detecting free margins was not macroscopically possible, additional biopsies along all the uncertain margins of the excision's residual area were taken. After excision, the specimen was mounted on a plastic support, flattened and then held in place with fine needles. It was then oriented and mapped. The pathologist measured the lesion's point of maximum infiltration and its distance from the free margins. RESULTS: Local and ultimate control at 36 months was 95% and 100%, respectively. We performed 29 partial and two complete cordectomies. Complete resection of the lesion was obtained in 90.4% of the cases. Re-resection was necessary in 9.6% of the cases due to positive margins. The anterior commissure was affected in 38.7% of the cases, and was the site of maximum infiltration in 9.6% of the cases. The mean maximum infiltration was 0.93mm in the anterior commissure, 2.18mm in the anterior 1/3rd of the vocal cord, 1.71mm in the middle 1/3rd of the vocal cord and 1.5mm in the posterior 1/3rd of the vocal cord. In 83.9% of the cases (p<0.01), the anterior 1/3rd of the vocal cord was the section most frequently involved. In 19 patients (61.3%) (p<0.01), the anterior 1/3rd of the vocal cord was also the area with the highest incidence of maximum infiltration by the tumor. CONCLUSION: We concluded that.     

CO2激光切除累及前联合的早期声门癌26例

目的 探讨CO₂激光切除侵犯前联合的早期声门癌的临床安全性及疗效。 方法 回顾性分析26例行CO₂激光治疗的侵犯前联合的早期声门型喉癌患者临床资料,肿瘤标本术中冰冻、术后HE染色行镜下切缘观察,术后严格随访观察局部复发情况。 结果 切缘阴性20例,阳性6例,随访3年中局部复发7例,复发率为26.9%(7/26),其中切缘阳性复发率为83.3%(5/6),切缘阴性复发率为10%(2/20),组间差异有统计学意义(P=0.002)。 结论 CO₂激光治疗累及前联合的早期声门型喉癌喉功能保全良好,疗效可靠,但需严格把握手术适应证以确保切缘安全,降低局部复发率。     

Vocal function following carbon dioxide laser surgery for glottic carcinoma

Vocal function following laser surgery for glottic T1a carcinoma was evaluated in 17 patients and compared to vocal function following radiotherapy in 14 patients. The results are summarized as follows. 1) A slight degree of hoarseness was found more frequently following laser surgery than following radiotherapy. The quality of hoarseness was rough and breathy in most cases. 2) In stroboscopic examination, incomplete glottal closure and diminution or lack of vibration of the operated vocal fold were frequently observed following laser surgery. 3) There was no marked difference in maximum phonation time, mean airflow rate, fundamental frequency range of phonation, intensity range of phonation, and intensity-flow ratio between the laser and the radiotherapy groups. On the basis of these results, we conclude that there is little difference in vocal function between postlaser and postradiotherapy patients as far as conversational voice is concerned.     

经口CO2激光治疗早期声门型喉癌术后嗓音分析

目的探讨经口CO2激光手术治疗早期声门型喉癌术后的嗓音情况。方法回顾分析2016年3月—2019年6月接受经口CO2激光手术治疗的48例声门型喉癌患者嗓音资料,根据手术是否切除前连合分为未切除前连组合（n=29）和切除前连合组（n=19）。分别于手术前和手术后6个月的嗓音稳定期对患者进行主观嗓音障碍指数量表简化中文版（VHI 13）评分、频闪喉镜检查及嗓音声学分析。结果经口CO2激光手术后6个月检查VHI 13生理评分及总分均较手术前明显减低;频闪喉镜检查未切除前连合组以声带黏膜波减弱或消失为主要表现,而切除前连合组术后出现前连合粘连和室带代偿性发音的比例明显升高;嗓音声学分析发现,与术前比较,激光手术后基频（F0）增加,基频微扰(jitter)和振幅微扰(shimmer)增大,最长发声时间(MPT)缩短,嗓音障碍严重指数（DSI）减低;未切除前连合组患者振幅微扰较切除前连合组更低,最长发生时间更长,DSI更高。结论声门型喉癌经口CO2激光手术后患者的主观嗓音质量较术前有一定程度的改善,是否切除前连合与术后声带形态、嗓音质量有密切关系。     

Our experience in CO2 laser surgery for early glottic carcinoma

In the years 1990-2002 187 patients were treated laser microsurgery due to T1, T2 laryngeal cancer. One of the purposes of this work was analysis of resurgery cases due to recurrence of neoplasmatic process after laser cordectomy, therefore a group of 93 patients, treated in the years 1990-1997 was controlled. The local recurrence of neoplasmatic process was observed in 13 persons. The changes were once more removed in laser microsurgery in 5 patients. In 8 persons total laryngectomy was performed with subsequent radiological treatment. The best results of treatment were observed in patients in whom changes were limited to medial part of vocal cord while recurrences were the most often in patients with anterior commissure lesion. In case of recurrences after laser microsurgery all other kinds of possible treatment can be applied as, partial conventional surgery, total laryngectomy, X-ray therapy or repeated laser microsurgery. Functional evaluation of voice in 64 patients, who due to early stage of carcinoma were submitted unilateral CO2 laser cordectomy, was performed. The appearance and mobility of larynx were registered and evaluated in particular periods post surgery, the patients voices were registered and acoustic analysis submitted. Gradual voice improvement following the wound healing were observed in subjective patients evaluation as in objective one. In many cases very good functional results were obtained, which made possible for patients after CO2 laser cordectomy to continue work requiring good function of larynx. In 43 patients the psychological aspect of laser microsurgery influence was analyzed by use of anonymous questionnaires. It proofed, that in the majority of cases, the laser surgery had no influence for the social and company life of people submitted laser cordectomy. In 7 patients the views of larynx were very specific on the free edge of scar after removed vocal cord--spherical structure of 3-5 mm diameter has appeared in 2 to 6 months after laser cordectomy. In pathological examination--laryngitis chronica, granulatio--was stated. In further observation of patients no recurrences were observed. The described changes resemble granulomas and the most probably are caused by laser ray. Higher power lasers are useful, even when used at the same wattage as older models as they produce less carbonization of tissue during use.     

CO2激光喉显微手术治疗早期声门型喉癌疗效观察及相关因素分析

目的探讨CO2激光喉显微手术治疗早期声门型喉癌的疗效和安全性,对手术注意事项进行探讨。方法在显微支撑喉镜下,对27例早期声门型喉癌患者采用CO2激光手术治疗,其中Tis6例,T1a8例,T1b7例,T26例。累及前联合者3例,未累及前联合者24例。结果全部患者CO2激光手术均成功,术后无一例患者出现呼吸困难、出血等严重并发症。随访3年以上,存活率100％。2例患者复发,其中1例行CO2激光喉显微手术再切除,1例行喉垂直部分切除并术后放疗,随访2年均未再复发。结论CO2激光喉显微手术是治疗早期声门型喉癌的有效方法,通过选择合适的患者及注意术中操作,可减少甚至避免显微喉镜激光手术引起的声带粘连。     

Local recurrence after CO2 laser cordectomy for early glottic carcinoma

OBJECTIVES: To point out prognosis factors of local recurrence after endoscopic cordectomies for Tis, T1a, T1b, and T2 glottic squamous cell carcinomas. STUDY DESIGN: A cohort of 110 patients treated from January 1990 to December 2000 at a single institution was retrospectively analyzed: 21 had Tis, 76 T1a, 7 T1b, and 6 T2 (mean follow-up 42 mo; range 1-160 mo). METHODS: The depth and extension of the excision were graded according to the European Laryngological Society Classification. Univariate analysis was used to review the impact on disease-free survival of factors related to the host, the tumor, and the treatment. RESULTS: According to the Kaplan-Meier method, the 5 year overall survival and the disease-free survival were 87% and 75%, respectively. The rates of cause-specific survival, ultimate local control with laser alone, and laryngeal preservation were 97%, 84%, and 90%, respectively. Univariate analysis by the log rank test revealed that vocal muscle infiltration (P = .001) and subglottic involvement (P = .02) have a significant impact on disease-free survival. Of the 22 patients with local recurrence (17 T1a, 1 T1b, and 4 T2), 9 were managed with total laryngectomy, 5 with partial laryngectomy, 4 with further laser cordectomy, 2 with radiotherapy, and 2 had no curative treatment. CONCLUSION: Transoral laser surgery for early glottic carcinoma is a valid alternative to radiotherapy and partial laryngectomy in terms of oncologic results. It offers low morbidity and excellent retreatment options in case of local failure. Careful patient selection for laser surgery is essential to secure good results.     

CO2激光手术治疗早期声门型喉癌疗效分析

目的：探讨经口内镜下CO2激光显微外科手术治疗早期声门型喉癌的疗效。方法：回顾性分析1999年10月～2004年8月接受CO2激光显微外科手术治疗声门型喉癌患者91例（Tis9例,pT1a45例,pT1b25例,pT212例）。声带切除方式按2000年欧洲喉科学会制定分类方案划分。结果：依照Kaplan-Meier方法计算5年局部无复发率：Tis100．00％,T1a93．33％,T1b84．00％,T275．00％,组间差异无统计学意义（P〉0．05）。病变侵犯前联合5年局部无复发率78．57％（6／28）,未侵犯前连合5年局部无复发率93．65％（4／63）,组间差异有统计学意义（χ2=4．348,PdO．05）。5年整体生存率92．72％,无瘤生存率84．62％。术后6个月GRBAS声音嘶哑评估：Ⅰ、Ⅱ型术后评分正常或轻度异常水平;Ⅲ、Ⅳ、Ⅴ型手术术后嗓音大部分有轻度至中度嘶哑音。结论：CO2激光显微外科对治疗早期声门型喉癌是有效的治疗方法。     

早期声门癌的内镜治疗

随着微创技术的不断成熟,早期声门型癌大多采取内镜下手术治疗。自上个世纪70年代CO₂激光引入早期喉癌的治疗以来,因其无颈部及气管切开、术后并发症少、住院时间短、病人恢复快、喉功能保存好等优点,越来越被广泛应用,已被公认为首选的内镜手术方式。就经口CO₂激光治疗早期声带癌的适应证、并发症、局限性、手术分型等内容进行讨论,在综述早期声门癌内镜治疗的历史及发展的同时,特别强调早期声带癌内镜手术中遵循肿瘤外科原则的重要性。