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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 23-26

Transoral laser surgery for supraglottic squamous cancers


Department of Surgical Oncology, Prince Aly Khan Hospital, Mumbai, Maharashtra, India

Date of Web Publication27-Jul-2017

Correspondence Address:
Rishav Garg
Department of Surgical Oncology, Prince Aly Khan Hospital, Nesbit Road, Mazagaon, Mumbai - 400 010, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_4_17

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  Abstract 

Objective: The objective of the study was to evaluate the oncological and functional results of transoral CO2laser microsurgery (TLM). Study Design: This is a retrospective study of squamous cancers of the supraglottis treated with transoral CO2laser resection. Materials and Methods: Between May 1997 and April 2014, 131 cases of T1/T2/T3squamous cancer of the supraglottis/hypopharynx with freely mobile vocal cords and no gross invasion of the laryngeal spaces, were resected transorally with the CO2laser. Results: Oncologically, resections performed under the magnification of the operating microscope are safe and yield high local control rates ranging from 79% to 85% for supraglottic cancer. For salvage of local recurrences following TLM, a full range of treatment options remains available including re-use of TLM. Of the 29 recurrences, 9 were salvaged with repeat TLM, 4 with radiotherapy, and 6 with total laryngectomy. In supraglottic cancer, management of neck is very important. Twenty patients with the clinically “N+” neck at presentation, underwent neck dissection at the same time of TLM or after an interval of 4–5 days. For the 111 “N0” cases, the neck was treated only if and when metastasis manifested at followup. Thus, nine patients underwent neck dissection for regional recurrence at followup. The neck was also treated in the local/locoregional recurrences salvaged either with radiotherapy or total laryngectomy. There were two cases of advanced regional recurrences that could only be offered palliative care.

Keywords: Functional outcome, oncological results, organ preservation, supraglottic and hypopharyngeal carcinoma, transoral laser microsurgery


How to cite this article:
Pradhan S, Garg R, Chaudhary A, Mehta M, Kannan R. Transoral laser surgery for supraglottic squamous cancers. J Head Neck Physicians Surg 2017;5:23-6

How to cite this URL:
Pradhan S, Garg R, Chaudhary A, Mehta M, Kannan R. Transoral laser surgery for supraglottic squamous cancers. J Head Neck Physicians Surg [serial online] 2017 [cited 2019 Jul 19];5:23-6. Available from: http://www.jhnps.org/text.asp?2017/5/1/23/211730


  Introduction and Aims Top


Open partial laryngectomies for supraglottic cancers have a very high incidence of aspiration in the postoperative period with resultant delay in restoration of swallowing. Majority of the early supraglottic cancers are treated with radiotherapy or chemoradiotherapy. The present study examines the functional efficacy and oncological safety of transoral CO2 laser microsurgery (TLM) for select subset of T1/T2/T3 squamous cancers of the supraglottis with freely mobile vocal cords that are easily accessible on suspension microlaryngoscopy.


  Materials and Methods Top


Between May 1997 and April 2014, a total of 131 cases of previously untreated squamous cancer of supraglottis were resected transorally with the CO2 laser in the Department of Surgical Oncology, Prince Aly Khan Hospital, Mumbai. Only a select subset of T1/T2/T3 supraglottic squamous cancers characteristics by superficially invasive previously untreated squamous cancers with freely mobile vocal cords, minimal or no invasion of laryngeal spaces, and accessible to transoral laser resection with good exposure on suspension microlarynopharyngoscopy were taken up for transoral laser microsurgery. The cases of transoral laser resection with benign tumors, nonsquamous cancers, recurrence of an already treated cancer, and simultaneous second primary were excluded from in this series.

Majority were marginal zone cancers. All the T3 lesions selected for TLM were T3 by virtue of their size or trans-regional extension. There was no invasion of laryngeal spaces, and vocal cords were freely mobile. The presence of lymph node metastasis did not preclude TLM for the primary. All resections were performed with curative intent and not just for debulking of tumor.

The policy for management of neck was if the neck was N+ clinically or on imaging a neck dissection was performed either simultaneously or after an interval of 4–5 days; if the neck was N0 a “wait and watch policy” was followed and neck dissection performed only when neck metastasis manifested; adjuvant treatment with radiation or chemoradiation was only given if the neck disease so demanded, namely, for capsular invasion or for N2/N3 disease. The larynx and hypopharynx were shielded from the radiotherapy field as much as possible.

Operative technique

Transoral laser microsurgery was performed under general anesthesia with orotracheal intubation. Exposure was achieved using a distending laryngopharyngoscope (Steiner's bi-valve adjustable laryngopharyngoscope) with an integrated tube for plume suction. A CO2 laser system (40c, Lumenis, Germany) was used with a micromanipulator attached to the operating microscope. The laser power used varied from 7 to 15 W super pulse.

A small lesion was resected en bloc. A large lesion may be seen very formidable to resect, but the procedure keeps getting easier as one starts resecting segment by segment. For a lesion in proximity to or even overlying the arytenoid, the cartilage was preserved by resecting the lesion through the supple submucosal plane. This preserved the posterior glottis bulk and prevented aspirations. A suction cautery was an absolute necessity for resecting supraglottic.

Statistical methods

All survival rates were calculated using the Kaplan–Meier method. Events included local and regional recurrences, distant metastasis, and deaths due to disease.


  Results Top


Out of 131 total cases, 101 were male and 30 were female.

Age ranging from 22 to 84 years (median 53 years).

All patients were classified according to the current UICC/AJCC classification.

Supraglottic cancers n = 131 (T1 – 46; T2 – 66; T3 – 19).

  • Neck Nodal status: Median follow-up was 54 months (range 24–140 months) [Table 1]
  • Primary treatment [Table 2].
Table 1: Neck nodal status

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Table 2: Primary treatment

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Oncologic results

  • Two-year local control rate for supraglottic cancers [Table 3]
  • Recurrences in supraglottic cancers (n = 35) [Table 4]
  • Salvage therapy after the first failure [Table 5].
Table 3: Two years local control rate for supraglottic cancers

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Table 4: Recurrences in supraglottic cancers (n=35)

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Table 5: Salvage therapy after the first failure

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Organ preservation in supraglottic cancers could be achieved in 39 cases (92.85%) of Stage I, 54 cases (96.42%) of Stage II, 15 cases (93.75%) of Stage III, and 8 cases (47.05%) of Stage IV.

Functional results

Most of the patients had an easy postoperative recovery phase. None of the patients needed a tracheostomy. Very few patients needed a feeding tube for 2–3 days postoperatively and this was generally not for aspiration but rather for odynophagia as a result of a large raw area in the vallecula following resection. Only one patient needed a feeding gastrostomy for prolonged period.


  Discussion Top


Open supraglottic partial laryngectomy and supracricoid partial laryngectomy with cricohyoidopexy, procedures that were often undertaken for early or intermediate stage supraglottic cancers are rarely resorted to today because of the prolonged periods of aspiration[1] following surgery and because of the availability of effective nonsurgical treatment options, namely, advanced techniques in radiotherapy and a combination of chemo and radiotherapy.[2]

The problem of postoperative aspiration following open voice conservation surgery was even more pronounced in early suprapharyngeal cancers.[3] So much so that the world over, most centres treated these cases only with nonsurgical treatment of radiotherapy or chemoradiation. If ever a surgical option was considered, it was either a total laryngectomy or a near-total laryngectomy even for an early cancer of the supraglottis.

The advent of TLM has added a new dimension to the treatment options in selected cases of supraglottic[4] larynx. These are T1, T2, T3 lesions that are superficially invasive, the vocal cords are freely mobile, and there is no gross invasion of laryngeal spaces. Most importantly, lesions should be accessible to TLM with good exposure on suspension microlaryngoscopy. The majority of these lesions are located on the marginal zone, the suprahyoid epiglottis, the aryepiglottic folds, and the pharyngoepiglottic folds.[5]

With the transoral approach, the main sensory nerve supply to the larynx remains undisturbed, and this helps a great deal in preventing aspiration and therefore allows early restoration of swallowing.[5],[6] Again, with transoral resection, the laryngeal framework remains intact obviating the need for a tracheostomy. Even if the lesion involves the mucosa over the arytenoid, under the magnification of the operating microscope, the tumor can be resected through supple submucosal tissue preserving the arytenoid which allows a good voice quality and also helps in preventing aspiration.[5],[7]

It is these advantages of no tracheostomy,[5],[8] no feeding tube,[5],[8] and smooth postoperative recovery[9] that allows transoral laser resection to be performed as a day care procedure in most cases with significant cost saving.

In the present series of 131 cases, barring one patient who needed feeding tube for a prolonged period, all others have had smooth postoperative recovery with early restoration of swallowing.[9]

In terms of disease control, the resection performed under magnification of the operating microscope is very effective for local control as evident in the results in this series.

The published results by Bocca[10] of open supraglottic partial laryngectomy for T1/T2/T3 squamous cancers are 2-year local recurrence rate of 16.5% (Stages I and II) and 21.5% (Stages III and IV).

It has been argued that such superficially invasive T1/T2/T3 squamous cancers of the supraglottis can also be very effectively treated with the nonsurgical treatment methods, namely, radiotherapy for smaller lesions or chemoradiation for the bulky lesions or those with N+ neck.[11]

While this is true, it is also a fact that radiotherapy and chemoradiotherapy are both more prolonged, more expensive and more toxic treatments they can cause severe mucositis and have long-term side effects of dryness of the mucosa.[12] Moreover, recurrences following radiotherapy cannot be re-radiated. These cases will need salvage total laryngectomy with very high complication rates because of poor healing and pharyngeal leak.[13] As against this if the primary is resected with laser, the larynx and hypopharynx are spared radiotherapy and its after effects. In case of recurrence following laser resection, all the treatment options are available for treating the recurrence including re-resection transorally with the laser or radiotherapy or open surgery.

In this present case of 131 cases treated with TLM 96 cases remained recurrence free. Of the 29 cases who developed local or locoregional, 14 cases were salvaged with repeat TLM and 04 with radiation therapy. Six patients with local/locoregional recurrence could only be salvaged with total laryngectomy. Another six patients had very advanced locoregional recurrence and could only be offered palliative treatment.

Overall, treatment with TLM is effective in yielding high local control rates that are no inferior to radiotherapy or chemoradiotherapy with advantages of a shorter treatment time, much better tolerance, and devoid of long-term side effects.

Another argument followed by the proponents of treatment with radiotherapy is the preference of TLM is that radiation for supraglottic cancers includes the cervical lymph nodes in the treatment fields since these cancers have a high propensity for lymph node metastasis.[11]

Prophylactically, radiating the neck while radiating the primary has been a standard practice for several decades and needs to be challenged.

If the neck is N+ at presentation, it is best to do neck dissection rather than radiate. In the present series, 20/131 cases were “N+” at presentation and underwent neck dissection either at same sitting as TLM or 4–5 days later. Sixteen of these were treated with adjuvant radiotherapy because the neck disease so demanded. The larynx was shielded in as far as possible.

In the remaining 111/131 cases, the neck was “N0” at presentation both clinically and on imaging. These were treated with TLM alone. Rather than subject this very large group of “N0” cases to prophylactic treatment of the neck with either radiotherapy or neck dissection, the authors prefer to pursue a vigilant “wait and watch” policy with regular follow-up, resorting to neck dissection only if and when lymph node metastases manifest.

At follow-up, ten patients who developed cervical lymph node metastasis underwent neck dissection with seven of these receiving adjuvant radiotherapy. As mentioned earlier sight patients developed advanced unresectable locoregional recurrence and could only be offered palliative treatment. Some of these patients with local recurrences who underwent salvage treatment with radiotherapy or total laryngectomy also had cervical lymph node metastasis that were tackled simultaneously with salvage of the primary.

All in all, by not radiating the neck prophylactically and instead following the “wait and watch” policy, the failure rate in the neck has been kept to the bare minimum. In more than 100 cases prophylactic treatment of neck has been avoided along with its inherent complications.


  Conclusion Top


TLM in selected cases of supraglottis squamous cancers is safe procedure with several advantages over the open partial laryngectomy procedures as also over radiotherapy.

In T1/T2/T3 cancers that are superficially invasive, the vocal cords are freely mobile, there is no gross invasion of the laryngeal spaces and there is adequate tranoral access, the resection performed under the magnification of the operating microscope is oncologically safe and functionally very well tolerated.

Functionally, following TLM tracheostomy is not needed and problems of aspirations in postoperative period are minimal, if at all. These are major advantages of TLM over the open partial laryngectomy procedures. As compared to treatment with radiotherapy, TLM has a much shorter treatment time and is devoid of long-term sequale of dryness of the mucosa. In case of local recurrence, TLM can be repeated whereas radiotherapy cannot be and often the only alternative is total laryngectomy.

Oncologically, TLM is safe because the resections are performed under the magnifications of the operating microscope.

For management of neck, following TLM if the neck is clinically “N+” it is dissected at the same time or after an interval of 4–5 days. If the neck is clinically “N0” a wait and watch policy is followed after TLM and treatment of the neck undertaken only if and when metastatic disease manifests. With this approach, failures in the neck are kept to bare minimum. As against this, if the treatment is with radiation therapy, the “N0” neck receives prophylactic radiation bilaterally.

This study was supported by Prince Aly Khan Hospital.

Financial support and sponsorship

This study was supported by Prince Aly Khan Hospital.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Benito J, Holsinger FC, Pérez-Martín A, Garcia D, Weinstein GS, Laccourreye O. Aspiration after supracricoid partial laryngectomy: Incidence, risk factors, management, and outcomes. Head Neck 2011;33:679-85.  Back to cited text no. 1
    
2.
Hutcheson KA, Lewin JS. Functional outcomes after chemoradiotherapy of laryngeal and pharyngeal cancers. Curr Oncol Rep 2012;14:158-65.  Back to cited text no. 2
[PUBMED]    
3.
Milisavljevic D, Stankovic M, Zivic M, Popovic M, Radovanovic Z. Factors affecting results of treatment of Hypopharyngeal Carcinoma. Hippokratia 2009;13:154-60.  Back to cited text no. 3
    
4.
Rodrigo JP, Suárez C, Silver CE, Rinaldo A, Ambrosch P, Fagan JJ, et al. Transoral laser surgery for supraglottic cancer. Head Neck 2008;30:658-66.  Back to cited text no. 4
    
5.
Pradhan S, Monnier P, Pai P. Surgery of the Larynx and Hypopharynx. Mumbai, India: Lloyds Publishing House; 2014.  Back to cited text no. 5
    
6.
Watkinson JC, Gilbert RW. Stell and Marans Textbook of Head and Neck Surgery and Oncology. UKL: Hodder and Stoughton Ltd.; 2012.  Back to cited text no. 6
    
7.
Shah JP, Patel SG, Singh B. Jatin Shahs Head and Neck Surgery and Oncology. Philadelphia USA: Elsevier; 2012.  Back to cited text no. 7
    
8.
Hinni ML, Salassa JR, Grant DG, Pearson BW, Hayden RE, Martin A, et al. Transoral laser microsurgery for advanced laryngeal cancer. Arch Otolaryngol Head Neck Surg 2007;133:1198-204.  Back to cited text no. 8
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9.
Kutter J, Lang F, Monnier P, Pasche P. Transoral laser surgery for pharyngeal and pharyngolaryngeal carcinomas. Arch Otolaryngol Head Neck Surg 2007;133:139-44.  Back to cited text no. 9
[PUBMED]    
10.
Bocca E. Supraglottic laryngectomy and functional neck dissection. J Laryngol Otol 1966;80:831-8.  Back to cited text no. 10
[PUBMED]    
11.
Mendenhall WM, Million RR, Cassisi NJ. Squamous cell carcinoma of the head and neck treated with radiation therapy, The role of neck dissection for clinically positive neck nodes. Wiley Online J 1988;10:302-4.  Back to cited text no. 11
    
12.
Jensen AB, Hansen O, Jørgensen K, Bastholt L. Influence of late side-effects upon daily life after radiotherapy for laryngeal and pharyngeal cancer. Acta Oncol 1994;33:487-91.  Back to cited text no. 12
    
13.
Furuta Y, Homma A, Oridate N, Suzuki F, Hatakeyama H, Suzuki K, et al. Surgical complications of salvage total laryngectomy following concurrent chemoradiotherapy. Int J Clin Oncol 2008;13:521-7.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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