声门癌的组织病理学研究—附62例连续切片观察

目的:探讨声门癌的发病特点,生长方式及向外扩展特点,声带固定的意义,术式选择与肿瘤复发率生和生存率的关系。方法:62例中,T_1 37例,T_2 9例,T_3 16例。仅1例为T_3N_1M_0,均为喉鳞癌。手术方法:喉全切除术16例,喉垂直部分切除术25例,声带切除术21例,N_1者行同侧颈廓清术。单纯声带切除标本采用石蜡包埋技术,其余采用火棉胶包埋技术,进行连续切片观察。结果:声门癌的生长方式与病理分期有一定关系。临床TNM分期与病理分期不符率为27.4％,估计过低是对喉骨架侵犯估计不足,过高是对肿瘤周围炎性浸润误为肿瘤范围。Reinke's层、弹力圆锥、声门旁间隙、喉室、甲状软骨都有一定的“屏障”作用,前联合受侵应考虑喉骨架可能受侵。术后局部复发率为12.8％,复发时间为3个月～8年,复发病例中以T_2为多。颈淋巴结转移率为4.8％,术后3年生存率98.4％,5年生存率95.2％。结论:声门癌颈部淋巴结转移率低,术后复发率低,生存率高。同侧上下扩展多见,晚期才向对侧扩展。前联合腱是肿瘤向对侧声带、甲状软骨和环状软骨侵犯的通道。声门癌侵及前联合者应考虑喉骨架可能受侵。声带固定不是喉部分切除禁忌证,而是扩大手术范围的指征。     

Treatment of early-stage glottic cancer by transoral laser resection

OBJECTIVES: We reviewed outcomes of treatment of early glottic carcinoma by transoral laser resection. METHODS: We performed a retrospective study of tumor stage, type of cordectomy (European Laryngological Society), resection margins, local control, and laryngeal preservation. RESULTS: Of 142 patients treated with curative intent, 79 (92% male; average age, 63 years) were retained for this study, on the basis of availability of information regarding resection margins, the absence of adjuvant radiotherapy, and followup of at least 2 years. The 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%). The average follow-up was 56 months (range, 24 to 150 months). The overall 5-year actuarial recurrence-free survival rate was 89%, and the 5-year actuarial disease-specific survival rate was 97.3%. There were 11 local recurrences (14%); 7 were treated by another laser resection, 1 by radiotherapy, 1 by supracricoid partial laryngectomy, and 2 by total laryngectomy. The overall rate of 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. The overall rate of organ preservation was 100% for patients with positive or suspicious margins and 96% for those with free margins. Margin status (p = .39), cordectomy type (p = .67), and anterior commissure involvement (p = .16) were not statistically related to recurrence (Kaplan-Meier calculations with nonparametric univariate analysis). The recurrence rate was significantly higher for T1b tumors, however (p = .001). CONCLUSIONS: Laser microresection provides high rates of local control and organ preservation for early glottic cancer. Positive or suspicious margins were not related to recurrence, nor was anterior commissure involvement. This study implies that suspicious margins can be managed with a "watch-and-wait" attitude. Re-treatment with laser, external partial laryngectomy, and radiotherapy remain therapeutic options for recurrences.     

Radiotherapy of early glottic cancer

Patients (383) with stage Tis, Tla and Tlb NoMo glottic cancer are reviewed. Radiotherapy cured 93% of Tis patients and 86% of Tla and Tlb cases. Of all recurrences, 63% were cured. No patient with stage Tis died as a result of tumor and only 5% of stage Tla and Tlb died from tumor. Involvement of the anterior commissure or both vocal cords did not influence control rates by radiotherapy. Mobility of the vocal cord and size of radiotherapy field were significant factors influencing control by radiotherapy. Late recurrences and/or second primaries in the larynx following radiotherapy are rare. Second primaries in the respiratory tract (especially lung) are common and are as important a cause of death as laryngeal cancer in Tl cases. It is concluded that moderate dose radiotherapy with surgery for salvage is a highly effective method of management for early glottic cancer.     

早期声门型喉癌治疗方式的评价与选择

早期声门型喉癌（early glottic cancer，EGC）通常是指Tis-T2病变且无颈淋巴及远处转移者。放疗与手术治疗，包括开放性手术、支撑喉镜下激光手术（简称激光手术）和非激光手术等，均是EGC的有效治疗手段，并具有相近的治疗效果。由于尚缺少理想的前瞻性随机对照研究，还没有足够的证据表明哪种治疗方式对EGC具有更好的治疗效果，对其治疗方式的选择亦缺少统一的意见，现将国内外的主流意见总结如下。     

嗓音显微手术治疗早期声门癌的远期疗效观察

目的观察应用嗓音显微手术治疗早期声门癌的远期疗效.方法1989-1997年采用嗓音显微外科技术对44例声带早期癌（T1a）进行了手术治疗.声带早期癌按病变的侵袭深度分为：原位癌（5例）、低侵袭癌（33例）和侵袭癌（6例）.原位癌和低侵袭癌采用微瓣切除技术;对侵袭癌则采取激光切除声带,切缘经过微波或激光处理的方法.每例患者均进行术前、术中和术后录像,术后常规病理送检,并进行长期随访.随访最长时间为11年,最短时间5年.结果应用微瓣切除方法的38例原位癌和低侵袭癌中有6例在手术后随访的2～3年内发现局部复发,局部复发率为15.8%.6例复发患者再次行微瓣切除,其中1例在10年内经历3次微瓣切除手术.1例失随访后1年再次因肿瘤复发就诊,后改喉全切除手术.微瓣切除术病例失访4例,其余随访5年以上均存活,5年生存率为89.5%（失访以死亡计）.应用声带切除术的6例早期侵袭癌中2例于术后2个月发现肿瘤复发而行喉切除术,1例失随访后3年复发改喉全切除术,1例梭型细胞癌术后采用局部放射治疗.声带切除术局部复发率为4/6;3例在3年内死亡,1例3年后失访,2例存活5年以上.结论对病变局限的早期癌,嗓音显微手术不仅能有效地治愈疾病,同时能保护和维持正常的发声功能.对于病变局限在黏膜表面的声带早期癌,嗓音显微手术的微瓣技术不仅是有效的微创治疗措施,同时微瓣切除的病变标本经连续切片的病理诊断也成为了早期声带癌诊断及鉴别诊断的“金标准”.     

Selective management of early glottic cancer

Seventy patients with stage I and II glottic cancer were treated at the University of Utah School of Medicine hospitals from 1980 through 1987. Forty-four patients had stage I cancer and 26 patients had stage II. The overall survival in the stage I group was 82%. Primary site control was 93% with only three deaths due to laryngeal cancer. Local control rates were 93% with CO2 laser excision, 80% with CO2 laser and irradiation, and 67% with radiation alone. Stage II glottic patients had an overall survival of 61.5% with a local control rate of 76%. Twenty-one of 24 patients were treated by full-course irradiation. Of the eight patients who recurred at the primary site, all were irradiation failures who had initial bulky disease and impaired vocal cord mobility. Selective CO2 laser excision was highly effective, whereas radiation therapy results were somewhat disappointing. Open partial laryngectomy should be considered in bulky stage II disease patients.     

Surgical options in radiotherapy-failed early glottic cancer

After failure of curative radiotherapy (RT), surgery is the main therapeutic option to control recurrent laryngeal cancer. Recurrences after RT for T1–T2 tumours of the glottic larynx are often diagnosed at a more severe stage than the original disease and, thus, usually treated by radical approaches. Our aim is to investigate the feasibility of more conservative strategies for proper treatment of post-RT recurred glottic cancer. We collected and reviewed our files from 1990 to 2006, selecting 75 patients which matched the following inclusion criteria: (1) patient was originally diagnosed with early stage squamous cell carcinoma of the glottic larynx (stage I–II according to 2010 TNM), (2) patient was treated by RT with curative intent, (3) patient presented a recurrence of disease after RT which was surgically treated at our Institution. T stage at first diagnosis was T1a in 41 cases (55 %), T1b in 12 (16 %) and T2 in 22 (29 %). At clinical examination of RT-recurred lesions, we documented advanced lesions (rT3–rT4) in 29 out of 75 patients (39 %). Overall, an upstage was reported for 56 % RT-recurred cancers, while 37.3 % remained at the same stage than the original tumour and 6.7 % were downstaged. Twelve patients (16 %) underwent salvage partial laryngectomy (SPL), while 63 (84 %) received a salvage total laryngectomy (STL). Multivariate analysis showed that rTNM according to the AJCC-UICC of 2010 was the only prognostic factor for both disease-free survival (p = 0.042) and overall survival (p = 0.004). Considering the prognostic impact of rT and rN we documented a statistical significance only in terms of overall survival for both factors (p = 0.004 and p = 0.04, respectively). Although STL remains the most frequent treatment choice for failures after RT in laryngeal carcinomas, SPL represents a valid option for selected patients with limited recurrence and can deliver good oncologic and functional results if performed according to careful indications.     

保留喉功能的T4声门癌的手术治疗

目的　探讨T4声门癌喉功能保留手术的方法和临床疗效。方法　对 1982～ 1998年间2 2例T4声门癌患者进行手术治疗 ,切除肿瘤及受累的软骨和喉外组织 ,以胸骨舌骨肌筋膜瓣、颈阔肌皮瓣、颈阔肌筋膜瓣、甲状软骨膜瓣、下咽黏膜瓣等修复组织缺损 ,保留会厌或环状软骨板重建喉功能。全部患者均接受术后放射治疗 (5 0 0 0～ 6 0 0 0cGy)。结果　全组病例 3年生存率 86 4 % (19/ 2 2 ) ,5年生存率 75 0 % (15 / 2 0 )。喉功能恢复 (吞咽保护、呼吸、发音 )为 6 8 2 % (15 / 2 2 ) ,喉功能部分恢复(吞咽保护、发音 ) 31 8% (7/ 2 2 )。结论　T4声门癌尽管可累及喉软骨和喉外组织 ,但经仔细选择的病例在彻底切除肿瘤的前提下保留喉功能是可行的     

T1b声门型喉癌的治疗进展

T1b期无淋巴结转移声门型喉癌属于早期喉癌,病变累及双侧声带,可包括前联合或后联合.临床治疗方法主要包括放疗、内镜下治疗及手术等.通过复习相关研究资料,对T1b期声门型喉癌各种治疗方法及进展做一综述.     

钬激光手术治疗早期声门型喉癌疗效分析

目的总结钬激光治疗早期声门型喉癌的疗效。方法对2004年2月～2009年3月应用钬激光手术治疗的36例声门型喉癌的疗效进行临床分析。结果 36例钬激光术后复发4例,局部复发率为11%（4/36）,颈部转移率为3%（1/36）,平均复发时间13.5个月;T1a复发率3.7%（1/27）,T1b复发率33.3%（3/9）,两组间差异有显著意义（P〈0.05）;36例患者因复发死亡2例,非相关疾病死亡2例,3年生存率89.7%（26/29）。结论钬激光治疗早期声门型喉癌疗效可靠、喉功能保全好、术后恢复快,是早期声门型喉癌的首选治疗方式之一。     

Three-dimensional reconstruction of the feline larynx with serial histologic sections

This paper reviews a new technique to develop high-resolution three-dimensional (3-D) images of the larynx using histological sections. Three-dimensional computer-reconstructed histological sections of the cat are used in this study to evaluate the recurrent laryngeal nerve (RLN) in its true anatomic course, with emphasis on its relationship to surrounding structures (laryngeal framework). A cat model was used because of specimen availability and technical ease of tissue preparation. Computer-reconstructed serial histologic sections add a new dimension to the study of laryngeal anatomy, laryngeal trauma, and growth patterns of laryngeal cancer. The technical aspects of three-dimensional reconstruction and future applications are discussed.