www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Prognostic
role
of
margin
status
in
open
and
CO
2
laser
cordectomy
for
T1a---T1b
glottic
cancer
夽
Vincenzo
Landolfo
a,
Carmine
Fernando
Gervasio
b,
Giuseppe
Riva
a,∗,
Massimiliano
Garzaro
a,
Rita
Audisio
a,
Giancarlo
Pecorari
a,
Roberto
Albera
baUniversityofTurin,SurgicalSciencesDepartment,1stENTDivision,Turin,Italy
bUniversityofTurin,SurgicalSciencesDepartment,2ndENTDivision,Turin,Italy
Received18June2016;accepted20November2016 Availableonline24December2016
KEYWORDS
Laryngealneoplasms;
Earlyglotticcancer; Marginstatus; Overallsurvival; Diseasefreesurvival
Abstract
Introduction:Cordectomybylaringofissureandtransorallasersurgeryhasbeenproposedfor thetreatmentofearlyglotticcancer.
Objectives:Theaimofthisretrospectivestudywastoevaluatetheprognosticvalueofmargin statusin162consecutivecasesofearlyglotticcarcinoma(Tis---T1)treatedwithCO2laser
endo-scopicsurgery(GroupA)orlaryngofissurecordectomy(GroupB),andtocomparetheoncologic andfunctionalresults.
Methods:Clinicalprognosticfactors,localrecurrencerateaccordingtomarginstatus,overall survivalanddisease-freesurvivalwereanalyzed.
Results:Marginstatusisrelatedtorecurrencerateinbothgroups(p<0.05)withoutsignificant differences betweenopenandlaser cordectomy(p>0.05).The 5yearsoverallsurvivaland disease-freesurvivalwererespectively90.48%and85.71%inGroupA;88.14%and86.44%in GroupB(p>0.05).Lowertracheostomyrate,earlierrecoveryofswallowingfunctionandshorter hospitalstaywereobservedinGroupA(p<0.05).
Conclusions:Margin status has aprognostic role inT1a---T1b glottic cancer. Transoral laser surgeryshowedsimilaroncologicresultsofopencordectomy,withbetterfunctionaloutcomes. © 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:LandolfoV,GervasioCF,RivaG,GarzaroM,AudisioR,PecorariG,etal.Prognosticroleofmarginstatusin openandCO2lasercordectomyforT1a---T1bglotticcancer.BrazJOtorhinolaryngol.2018;84:74---81.
∗Correspondingauthor.
E-mail:giuseppe.riva84@gmail.com(G.Riva).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2016.11.006
1808-8694/©2016Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE Neoplasiaslaríngeas; Câncerglóticoinicial;
Estadodemargem;
Sobrevidaglobal; Sobrevidalivrede doenc¸a
Papelprognósticodoestadodamargemcirúrgicanacordectomiaabertaecomlaser deCO2emcâncerglóticoT1a-T1b
Resumo
Introduc¸ão: Cordectomiaporlaringofissuraecirurgiatransoralalasertêmsidopropostaspara otratamentodocâncerglóticoinicial.
Objetivos: Oobjetivodesseestudoretrospectivofoiavaliarovalorprognósticodoestadoda margemem162casosconsecutivosdecarcinomaglóticoinicial(Tis-T1)tratadocomcirurgia endoscópicaalaserdeCO2(GrupoA)oucordectomiaporlaringofissura(GrupoB)ecomparar
resultadosoncológicosefuncionais.
Método: Foramanalisados fatoresprognósticosclínicos,taxaderecorrência localdeacordo comoestadodamargem,sobrevidaglobalesobrevidalivrededoenc¸a.
Resultados: Oestadodemargemestárelacionadoàtaxaderecorrênciaemambososgrupos (p<0,05)semdiferenc¸assignificativasentrecordectomiaabertaecirurgiaalaser(p>0,05).A sobrevidaglobaldecincoanoseasobrevidalivrededoenc¸aforam,respectivamente,90,48% e85,71%noGrupoA;88,14%e86,44%noGrupoB (p>0,05).Menortaxadetraqueostomia, recuperac¸ãomaisrápidadafunc¸ãodedeglutic¸ãoemenortempodeinternac¸ãoforam obser-vadosnoGrupoA(p<0,05).
Conclusões: OestadodamargemtempapelprognósticonocâncerglóticoT1a-T1b.Acirurgia alasertransoralmostrouresultadosoncológicossemelhantesaosdacordectomiaaberta,com melhoresresultadosfuncionais.
© 2016 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Laryngealcarcinomamakesuplessthantwopercentof can-cersworldwide,eventhoughttheincidenceisincreasing.1,2 Glotticcarcinomasrepresentthemajorityoflaringeal can-cer cases.2,3 Moreover, ‘‘early’’ glottic cancer (Tis, T1a, T1b, T2) is one of the most curable malignancies in the head and neck. The reason is not only an early diagnosis allowed bythe symptom of hoarseness, but alsoa preva-lencelessthan1%ofpatientswhodevelopsregionallymph node metastasis, as a result of the glottis peculiar lym-phaticdrainage.1 Differentsurgical techniques have been described.Cordectomyviathyrotomyistheoldestsurgical procedure for the treatment of laryngeal cancer.4 At the beginning ofthe 20thcentury (1915)Lynch etal. treated glotticcarcinomawithendoscopicapproach.5In1972Strong andJakointroducedCO2lasertechnologyinthesurgeryof
glottic malignancies (transoral laser cordectomy --- TLC).6 Highratesoflocalcontrolandlaryngealfunction preserva-tionhavebeenshownforpatientswithearlyglottictumors treatedwithtransorallaserresectionoropenpartial laryn-gealsurgery.Radiotherapy(RT)isanotherfeasibleoptionfor thetreatmentofglotticcancer.7Theevidencesuggeststhat surgeryandRTprovidehigherinitiallocalcontrolratesthan exclusive chemotherapy.8 Besides cure, laryngeal function preservationhasbeenaddedasaprimarygoaloftreatment nowadays.3,4,9 Additionalgoalsincludeminimizing therisk ofcomplicationsandloweringthecosts.3,6,10
Theaimofthisretrospectivestudywastocomparethe oncologicresults (accordingtothe 2010revised American Joint Committee onCancer classification)11 in a seriesof 162 casesof early-stage glotticcarcinoma (Tis, T1a,T1b)
treatedwithCO2laserendoscopicsurgeryorlaryngofissure
cordectomyatourDivisions.Ourattentionfocusedon clin-ical prognostic factors that potentially have a significant impact on local disease control and survival, such as pT classificationandmarginsstatus.Furthermore,clinical out-comes,suchasswallowingfunctionandtracheostomyrate, havebeenanalyzed.
Methods
Between January 1995 and December 2010, 214 patients withearlyglotticcancer(Tis,T1a,T1b)weretreatedatour Divisions.Forty-sevenpatients underwentexclusive radio-therapyand167patientsweresurgicallytreated.InourENT divisions,patients weresurgically treatedin the majority ofthecases.However,thefollowingcriteriaforindicating surgery or radiotherapy were used: feasibility of cordec-tomy,sequelaeof cordectomy andradiotherapy,patient’s comorbidities, and patient’s will. Five patients were lost atfollow-up (3underwent lasercordectomy and2 under-went open cordectomy). One-hundred 62 patients were includedinthe study.Male/femaleratiowas157/5.Mean agewas67.24±10.96years(agerange41---81years). Writ-teninformedconsentwasobtained.Exclusioncriteriawere: presenceofnodalanddistantmetastasis,tumorrecurrence (tumorrelapsethatoccurred6monthsor moreafter pre-vioustreatment), previous treatmentfor laryngeal cancer with laryngeal surgical procedures (except biopsy) or RT (i.e.cordectomies performed for tumor persistence after radiotherapy or surgery, within 6 months after previous treatment).
Table1 Patientsandtumorcharacteristics.
Characteristics N◦ofpatients(%)
GroupA(86pts) GroupB(76pts) Total(162pts)
Sex Male 83(97) 74(97) 157(97) Female 3(3) 2(3) 5(3) Smoker Currentsmokers 57(66) 60(79) 117(72) Formersmokers 24(28) 13(17) 37(23) Notsmoker 5(6) 3(4) 8(5) Alcoholconsumption Yes 58(67) 46(60) 104(64) No 28(33) 30(40) 58(36) Histologicaltype
Squamouscellcarcinoma 86(100) 76(100) 162(100)
Tumor(pTNMVIed.) Tis 15(18) 13(17) 28(17) T1a 50(58) 47(62) 97(60) T1b 21(24) 16(21) 37(23) Adjuvanttreatment Radiotherapy 8(9) 6(8) 14(9)
Patients’meanage
GroupA 68.54±10.81years,range45---81years GroupB 65.68±11.45years,range41---76years Total 67.24±10.96years,range41---81years
Patientsweretreatedwithtwodifferentsurgical tech-niquesbasedonsurgeons’experience.GroupAincluded86 patients treatedwith transoralCO2 laser-assisted
cordec-tomy.GroupBwascomposedby76patientswhounderwent
cordectomybyopenapproach.Themajorityofthepatients
of Group B were treated between 1995 and 2000. Five
patients with unsatisfactory glottic exposure (due to
ankylosingspondylitis,fractureofcervicalspine,
mandibu-lar deformity, short thick neck associated with marked
prognathism)12 underwent open cordectomy after
diagno-sis with biopsy performed with direct microlaryngoscopy (Group B). Some of the patients who underwent open cordectomy (Group B) were eligiblefor transoral cordec-tomy.However,inthefirstyearsofthisretrospectivestudy, theyunderwentopen cordectomy becauseof the surgical abilityofthesurgeon.Thetwogroups werehomogeneous forage,sex,tobaccoandalcoholconsumption,tumorgrade and stage, and comorbidities. At diagnosis 117 patients werecurrentsmokers,while37patientswereformer smok-ers;104patientswerecurrentdrinkers.Clinicalevaluations and pathological data are summarized in Table 1. Four-teenpatientsunderwentadjuvantradiotherapy.Criteriafor choosingadjuvantradiotherapyinpositivemarginpatients were:gradingofthetumor,feasibilityofawiderexcision, sequelaeof awiderexcision, patient’scomorbidities,and patient’swill.
Pre-operativestaging
Beforesurgicalprocedureallpatientswereexaminedwith fiberopticflexibleendoscope.Computedtomography (CT)
was performed in all patients with suspect of malig-nancy. Biopsy for diagnosis wasperformed when an open cordectomy was expected. In the laser group biopsy was performedinpatientswithasuspectedinvolvementof ante-riorcommissure,ventricle,arytenoidsand/orsubglottis.In 7casesoftypeIlasercordectomyforprobablebenignlesion, suchasleukoplakia,thepathologicaldiagnosis resulted in TisorT1asquamouscellcarcinoma;thereforeatypeIIIor widerlasercordectomywasperformed.Theclinicalstaging was conducted according to the American Joint Commit-teeonCancerclassification.11Thepathologicaldiagnosisof glotticsquamouscellcarcinomawasachievedafterlesion excision.Incaseofdiagnosticbiopsytheventriclewas con-trolledusing0◦ and70◦ scopesandbypalpationunderthe operative microscope.The feasibilityofCO2 laser
cordec-tomywasevaluatedduringendoscopicprocedures,whether perfectexposureoftheanteriorcommissurewaspossible.In allcasesthespecimenswereremoveden-bloc.Each spec-imenwasorientated andthe marginswere identifiedand marked with ink. The histological grade was determined accordingtoAnneroth’sclassification.13
CO2laserassistedexcisiontechnique
TLC consisted in radical resection of a specimen includ-ing the tumor itself and a margin of about 1---2mm of macroscopicallyhealthytissue.Allsurgicalprocedureswere performedundergeneralanesthesiaafteroro-tracheal intu-bationwithLaserMackinckrodtMedicaltubeswithinternal diameters ranging from6.0 to 7.0mm. Different laryngo-scopes were used to obtain laryngeal exposure. A Leika
M400Emicroscope with 400mm focallens coupledwith a DekaMedicalElectronicaCO2laserwasused.Pulsedenergy,
meanpower in Watt,and excisiondepth weretailored to carcinomalocalizationandcordectomytype.Cordectomies wererevisedaccordingtotheEuropeanLaryngological Soci-etyclassification.14
TypeIIIcordectomywasperformedin45patients(52.3%), type IV cordectomy in 20 (23.3%), type V cordectomy in 17(19.8%) andtypeVIcordectomy in4 cases(4.6%).Two patients(2.33%)underwenttracheostomy,toprotectlower airwayswhentherewasahighriskofpost-operative bleed-ingand/oredema.
Opencordectomy/cordectomybylaringofissure
External cordectomy wasperformed througha laryngofis-sureasdescribedbyBuck15:verticalcervicalincisioninthe middleline,sectionofthewhitelinetoexposethelarynx andtrachea,openingof thethyroidprominenceand exci-sionof thediseased (neoplastic)vocal cordtogetherwith itsparaglotticspace.Duringsurgicalprocedure,6patients (7.89%)underwenttracheostomy,usingCiaglia’stechnique orPortexGriggs’tracheostomykit,toprotectlowerairways whentherewasahighriskofpost-operativebleedingand/or edema.
Marginsstatus
Intraoperativebiopsieswereperformedonlyincaseof sus-picionofincompletetumor resection.Histologicalanalysis of resectionmargins wasperformed by thesame teamin all cases, with the same technique and criteria. Surgical specimenswerefixedin4%formaldehydefor48h,inkedon theirsuperficial(mucosal)anddeepsideswithtwo differ-entcoloredinksbeforeinclusionintheirentirety.Thenthey wereslicedaxially(paralleltothevocalfolds)with3---4mm thickness. Positive margins were defined by ‘‘in situ’’ or invasivecarcinomaincontactwiththemargin, close mar-ginswascharacterizedby1mmorlessbetweenmarginand tumor, and negative margins was characterized by a dis-tancegreaterthan1mm.Allspecimenswerereassessedby apathologist.
Follow-up
In patients with negative margins, clinical evaluations (including flexible laryngoscopy, videostrobolaryngoscopy, or both)wereperformed every3 monthsinthefirstyear, every 4---6 months during the second year, and annually for the next years. Patients with close margins, positive marginsoraprecancerouslesion (mildtomoderate laryn-geal intraepithelialneoplasia) wereassessed everymonth for first6months,every2 monthsforthe next6months, every 3 months for the next year, every 6 monthsin the thirdyearandannuallyforthenextyears.Repeated micro-laryngoscopyand excisionalbiopsies wereperformed only whenrelapsesweresuspected.Themeanfollow-upperiod was76.6months(range25---148months).Allpatientshadat leasta24monthfollow-upperiod.Onehundred-twenty-two patientshadatleast5yearfollow-upperiod:63ofGroupA
(10Tis,37T1a,16T1b)and59ofGroupB(8Tis,39T1a,12 T1b).
Statisticalanalysis
GraphpadPrismfor Windows,version 5,wasusedfor sta-tistical analysis. The Kaplan---Meier method and the Cox regression test were used for survival analysis curves. Comparisonamongqualitativevariableswasperformedby meansof2-test(orFisher’sexacttestwhennecessary).All
statisticaltests receivedthesame level ofsignificance of 0.05.
Results
Concerningpatientsandtumorcharacteristics(Table1),no statisticallysignificantdifferencewasobservedbetweenthe twogroups(p<0.05).
Positivespecimenmarginswerefoundin 11patientsin GroupA(onepatientunderwentsalvagesurgery,8patients were treated with radiotherapy and 2 had a watchfull-waiting follow-up),and 8 patients in Group B(6 patients underwent adjuvant radiotherapy and 2 had a watchful-waitingfollow-up).Patientswithdefinitivepositivemargins hada microscopicinvasion ofthe superficial and/or deep margin,sothesurgeondidnotsuspectitatoperativetime. Positive intraoperative margins were found in 3 patient of Group A, who underwent a wider laser surgery, and 2 patientsinGroup B,whounderwentawidersurgical exci-sion.
Definitivehistologicalexamwasnegativeforcarcinoma in 2patients of Group A(2.32%) and 3 patients of Group B(3.94%) (p=0.10). In these cases the whole tumor was resectedduringthebiopsyprocedure.
InGroupA,recurrenceofdiseaseoccurredin2patients outof86(2.32%)within2yearsoffollow-up,whilein6cases (6.97%)recurrencewasobserved within5 yearsof follow-up.ConcerningGroup B,1 patientsout of76 (1.31%)had recurrencewithin2years,and5patientsoutof76(6.58%) within5years.Thedifferencewasnotstatistically signifi-cant(p=0.10).Marginstatusisrelatedtorecurrenceratein bothgroupsanditisreportedinTable2.Nostatistically sig-nificantdifferencewasfoundbetweengroupsaccordingto marginstatus.InGroupA,5patientsaffectedbyrecurrence underwentsalvagesurgerywithlasertechnique(2patients), supracricoidlaryngectomy(1patient)ortotallaryngectomy (2patients),while4patients weretreated with chemora-diotherapy, according topatients’ comorbidities andwill. ConcerningGroup B,salvage surgery withpartial or total laryngectomy was used in 4 patients with recurrence (2 patientsunderwentsupracricoidsurgeryand2patientstotal laryngectomy). In Group B, chemoradiotherapy was per-formedin2casesandinonecase recurrencewastreated withradiotherapyalone.
The2-yearoverallsurvival(OS)ratewas97.67%inGroup A and 96.05% in Group B. Comprehensively,5 out of 162 patients(2inGroupAand3inGroupB)diedwithin2years, forcardiovascularaccidentorsecondprimarytumor(lung). Noexituswasrelatedtoglotticcancer.The 5yearoverall survivalrate was90.48% in Group A and 88.14% in Group B.Log-ranktestshowsthatthisdifferencewasnot
statisti-Table2 Localrecurrencerateaccordingtomarginstatus.
Marginstatus GroupA GroupB p
N◦pts Localrecurrencerate N◦pts Localrecurrencerate
Negative 60 5(8.33%) 64 5(7.81%) 0.80
Close 12 1(8.33%) 2 0(0.0%) 0.07
Positive 14 3(21.42%) 10 2(20.00%) 0.21
Entiresample 86 9(10.20%) 76 7(9.21%) 0.10
Table3 Overallsurvival(OS)anddiseasefreesurvival(DFS)accordingtoCTstage.
Follow-up GroupA GroupB
OS DFS OS DFS
2years 5years 2years 5years 2years 5years 2years 5years Entiresample 84(97.67%) 57(90.48%) 83(96.51%) 54(85.71%) 73(96.05%) 52(88.14%) 73(96.05%) 51(86.44%) Tis-T1a 64(98.46%) 43(91.49%) 63(96.92%) 42(89.36%) 59(98.33%) 42(89.36%) 59(98.33%) 42(89.36%) T1b 20(95.24%) 14(87.50%) 20(95.24%) 12(75.00%) 14(87.50%) 10(83.33%) 14(87.50%) 9(75.00%)
OS,overallsurvival;DFS,diseasefreesurvival.
callysignificant(p=0.30).Onlyonepatientoutof162died forrelatedtumorreason:bleedingoccurredduringsalvage surgeryforlaryngealtumorrecurrence.Otherdeathswere relatedtocardiovascularaccidentsorlungandesophageal malignancies.
Thediseasefreesurvival(DFS)rateat2yearswas96.51% inGroupAand96.05%inGroupB.Thediseasefreesurvival
at5 yearswas85.71% inGroup Aand 86.44%in Group B.
Log-ranktestshowsthatthisdifferencewasnotstatistically significant(p=0.25).
PatientsofGroupAandGroup Bwerestratifiedin two
subgroups according to cTNM classification (Tis-T1a and
T1b).Comprehensiveoncologicresults(overallsurvivalrate, OS;disease-specificsurvivalrate,DFS)stratifiedaccording toCTstagehavebeensummarizedinTable3andFig.1 (p-valuesfor Tis-T1a andT1b were the followings:0.58 and 0.53forOSand0.22and0.74forDFS,respectively).Organ preservationwassimilarinthetwogroups(2total laryngec-tomywereperformedineachgroupforrecurrentdisease). Functional outcomes, such as mean time needed to restore swallowingfunction and tracheostomy rate, were evaluatedinbothgroupsandcompared.InpatientsofGroup A, mean time of swallowing function recovery was 1.76 days(range1---4 days);while inGroup B it was5.51 days (range3---7days).Tracheostomywasperformedin2patients (2.33%)ofgroupAandin6patients(7.89%)ofGroupB.No pharyngeal fistulae was observed. Both these differences were statistically significant (p<0.05). Hospital stay was
significantlyreducedinpatientofGroupA(meantime:3.19 days)versuspatientofGroupB(6.34days)(p<0.05).These resultsarereportedinTable4.
Discussion
The roleofopen surgeryfor themanagementoflaryngeal cancerhasbeengreatlydiminishedduringthepastdecade. Thedevelopmentoftransoralendoscopiclasermicrosurgery (TLC), the improvements in delivery of radiation therapy (RT)andtheadventofmultimodality protocols,have sup-plantedthepreviouslystandardtechniquesofopenpartial laryngectomyforearlycancer.16
Anatomically, early laryngeal cancer is defined as an invasive cancer confined to the three layers of the lam-ina propria, and not invading the adjacent muscles and cartilages.17However,intheliterature,thetermisgenerally usedforTis,T1,T2lesionsasagroup.
Accordingtoliterature,18---22 ourstudy showedthat the oncologicresultsoflasersurgeryforselectedpatientsinthe treatmentofTis---T1laryngealcancerareequivalenttothose achievedwithopenpartiallaryngectomywithlessmorbidity andusuallywithouttheneedfortracheostomy.Thecurrent literatureisnowconcentratingonthecomparisonoflaser surgeryandradiotherapy.
Our study focused on margin status and a prognostic role was proven in both group of patients. Concerning
Table4 Functionaloutcomesaccordingtotreatment.
Functionaloutcomes GroupA GroupB p
Tracheostomy(%) 2.33 7.89 0.04
Swallowingfunctionrecovery(days) 1.76±1.23 5.51±2.04 0.02
100 80 60 60 Follow–up (months) Entire sample Ov er all sur viv al, % 40 40 20 20 0 0 100 80 60 60 Follow–up (months) Entire sample
Disease free sur
viv al, % 40 40 20 20 0 0 100 80 60 60 Follow–up (months) Tis–T1a Tis–T1a Ov er all sur viv al, % 40 40 20 20 0 0 100 80 60 60 Follow–up (months)
Disease free sur
viv al, % 40 40 20 20 0 0 100 80 60 60 Follow–up (months) T1b T1b Ov er all sur viv al, % 40 40 20 20 0 0 100 80 60 60 Follow–up (months)
Disease free sur
viv al, % 40 40 20 20 0 0 Group A Group B
Figure1 Overallsurvival(OS)anddiseasefreesurvival(DFS)Kaplan---MeyercurvesaccordingtoCTstage.
management of patients with positive or close margins,
nowadaysthereisnoconsensusaboutpost-operative strate-gies.Someauthorsrecommendedbiopsy;23itisnotunusual that final histological analysis is less favorable than the extemporaneous analysis, discovering non-negative mar-gins.Theproblemfortheclinicianisthentodecidebetween surveillance,surgicalrevisionandradiationtherapy.24Some studiesfound thatpositivemarginsaftercarefulresection inmacroscopicallyhealthytissuearenotapejorativefactor foroverallorrecurrence-freesurvivalinT1apatients endo-scopically treated.25---27 Therefore, adjuvant treatments, such as radiation therapy or surgical revision, do not seem indicated. In case of macroscopically negative,but microscopicallypositivemargins,someauthorsrecommend endoscopiccontrolwithtargetedbiopsyundergeneral anes-thesia10weeksaftersurgery.28---30
Other authors observed that positive margins after tumorresectionareassociatedwitha higherrateoflocal recurrences.31---33 Ansarin etal. found that whenthe mar-gins werepositive, the incidence of localrecurrence was higherandDFSwaslower(76.7% at84 months)compared topatientswithfreemargins.These findingsindicatethat additionaltreatmentshouldalwaysbegivenifpositive mar-ginsarefound.34
Inourstudypositivemarginswerefoundin24patients; 17 of them underwent adjuvant RT while 5 were treated with surgery. Two patients were managed with watchful waiting approach because of anesthesiological problems and radiation therapy refusal. According to literature, local recurrence rate was higher in patients with posi-tive margins.35 We did not find statistical differences in localrecurrence rate between laser and open surgery. In
2patientsofGroupAand3patientsofGroup Bdefinitive histologicalexamwasnegativeforcarcinoma.
Beyond oncologic results, other evaluated outcomes in literature are morbidity, vocal function, hospitaliza-tion length and costs. When performing cordectomy by laryngofissure,thethyroidcartilageandendolaryngealsoft tissuesaredivided.Sometimesaftersurgerytherecouldbea compromiseoftheairwaysandthereforeaneedfor tempo-rarytracheotomy.Withendoscopicresection,tracheostomy isveryrarelyindicated. Avoidingtracheotomyand preser-vingthe prelaryngeal muscles can facilitate a quick,safe recovery of swallowing.36 Functional results withTLC are generallybetterthanthoseofconventionalopensurgery,in termsof timeneeded torestore swallowing,tracheotomy rates, incidence of pharyngeal fistulae and shorter hospi-talstays.37,38 These functionalbenefits maybeattributed tothe more conservative natureof the endoscopic tech-nique,sincenormaltissuesarenotinterruptedduringthe procedure.36 In fact, in transoral laser cordectomies, the functionalsequelaeareexclusivelyvoice-related. Difficul-tiesinswallowingliquidsaftertheprocedurearetemporary andresolvespontaneouslyinafewdays.39 Ourresults con-firmedthe data reported in literature regardingneed for tracheostomyandswallowingfunctionrecovery.
In literature and in our study, the use of CO2 laser
surgery was associated with a shorter hospital stay and earlier return to work than laryngofissure cordectomy.40 For these reasons, CO2 laser cordectomy resulted as a
cost-effective treatment modality if compared to open cordectomy or radiotherapy.41---43 In particular, Cragle and MandeburgobservedthatCO2lasercordectomywasalmost
58% cheaper than radiotherapy with the same oncologic results.In1994,astudyofMyersobtainedasimilarresult: CO2surgeryis70%cheaperthanradiotherapy.
Thecostsincludedhospitaladmissionandstay,materials andsurgicaltime,aswellashealthcareandnon-healthcare personnel associated with the procedure. Specifically, it indicatedthattransorallasercordectomywaslessexpensive thanlaryngofissurecordectomy.Furthermore,open cordec-tomycostsincreasebecauseofthelaterreturntowork.
CO2lasercordectomyandopencordectomyafford
opti-mal oncologic radicality for early glottic cancer. Besides cure, compared to laryngofissure, CO2 laser cordectomy
offers different advantages. The absence of need for feeding tube or tracheotomy after CO2 laser procedure
eliminates two of the great stigmas regarding laryn-gealcancer treatment.Furthermore, amoreconservative approach guarantees a shorter hospitalization and lower costs.Finallytransoralapproachisrelatedtoalowerrisk ofcomplications.
Conclusions
Marginstatushasanimportantprognosticrolebothinopen cordectomyandin CO2 lasercordectomy. Therefore
addi-tionaltreatment should be considered in case of positive margins;inordertoreducerecurrencerateandconsequent needofmoreaggressivesurgery.Concerningmanagementof patientswithclosemargins,furtherstudiesarenecessaryto obtainaconsensusaboutpost-operativestrategies.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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