Учебники / Lasers in Otorhinolaryngology Huttenbrink

surgery incurred only about one-third the costs of radiotherapy. Brandenburg [50] calculated that the costs of radiotherapy were 15 times higher compared with laser surgery. These figures confirm the importance of cost calculations and suggest that as medicine becomes more costconscious, laser microsurgery will become an increasingly important treatment option for early glottic carcinoma.

Glottic Carcinoma with Involvement of the Anterior Commissure

Whether laser microsurgery is appropriate for glottic carcinoma with involvement of the anterior commissure is still controversial. While carcinomas rarely arise from the anterior commissure itself, it is very common for lesions of the vocal cord to extend to the anterior commissure. The peculiar anatomy of this region, with an absence of perichondrium at the vocal cord insertion, the extension of the vocal cord fibers into the thyroid cartilage, and the connections between the intraand extralaryngeal blood vessels and lymphatics [58–60], facilitates the infiltration of the thyroid cartilage by vocal cord lesions and their extralaryngeal spread through the cricothyroid ligament. Kirchner and Carter [61] observed in serial organ sections that T1a and T1b carcinomas rarely infiltrate the thyroid cartilage. On the other hand, carcinomas of the anterior commissure that have invaded the cartilage typically show supraglottic extension to the petiole region, subglottic extension, or both (T2 carcinomas) [61, 62].

In 1989, Krespi and Meltzer [63] reported on the laser resection of glottic carcinomas involving the anterior commissure in five patients. All the patients developed local recurrence. This prompted animal studies to investigate the possibility of microlaryngoscopic exposure of the anterior commissure. Because the resection apparently did not reach the anterior commissure in the experimental animals as well, the authors warned of the tendency for carcinomas in this region to recur after laser surgery. Other authors also reported incomplete resections of tumors involving the anterior commissure as a result of inadequate exposure and a tangential view of the operative site. Based on the numerous recurrences, the authors concluded that glottic tumors with anterior commissure extension were generally a contraindication to endoscopic laser surgery [63–66]. Other authors, however, were able to show that the adequacy of tumor resection in the anterior commissure depends on the degree of commissure exposure and that these lesions can be reliably resected by an experienced surgeon using proper instruments [16, 17, 22, 23, 67–70].

Results of Laser Microsurgery

We investigated the effect of anterior commissure extension on recurrence rates, organ preservation, and survival rates in 263 patients with previously untreated T1a, T1b, and T2a glottic carcinomas who underwent laser microsurgery at our Göttingen center between 1987 and 1996. We found that involvement of the anterior commissure by carcinoma at these T stages did affect local tumor control and

organ preservation but did not affect patient survival rates. The Kaplan–Meier 5-year local control rate for T1a lesions with anterior commissure involvement was 86 %, compared with 75 % for T1b lesions and 78 % for T2a lesions. The larynx was preserved in 93 % of the patients with T1a lesions involving the anterior commissure, 88 % with T1b lesions, and 93 % with T2a lesions. With carcinomas that did not involve the anterior commissure, the 5-year local control rates were 95 % for T1a lesions, 93 % for T1b lesions, and 83 % for T2a lesions. The larynx was preserved in 99 %, 94 %, and 97 % of the patients, respectively [71].

Some recurrences are definitely the result of inadequate primary resection. In our experience, adequate exposure of the anterior commissure is absolutely essential for prevention of tumor recurrence. Exposure can be improved by using a small, closed laryngoscope and applying external pressure to the laryngeal skeleton, providing the surgeon with a direct rather than tangential view of the subglottis. Resecting the most anterior portions of the ventricular folds can help improve exposure of the vocal cords, although uninvolved tissue in this area should be resected very sparingly as a rule, since the ventricular folds are useful for subsequent voice rehabilitation. Carcinomas of the anterior commissure should always be resected en bloc under high magnification. The vocal cord insertion on the thyroid cartilage is completely removed along with the surrounding perichondrium. If subglottic tumor growth is visible below the anterior commissure, the resection should be extended to the inferior border of the thyroid cartilage to ensure that extralaryngeal tumor spread around the inferior edge of the thyroid cartilage is not missed. The cricothyroid ligament is also completely resected if necessary (Fig. 6.5). In difficult cases, a second-look laser excisional biopsy should be performed approximately 6–8 weeks later to exclude residual tumor.

Fig. 6.5 Carcinoma of the anterior glottis. a Lines of resection. b Resection of portions of the cricothyroid ligament for subglottic tumor extension. c Resection of portions of the thyroid cartilage for infiltration of the cervical soft tissues (diagrams from [4]).

Involvement of the anterior commissure is also associated with increased recurrence rates following primary radiotherapy and frontolateral partial laryngectomy. The local control rate after primary radiotherapy for a T1 carcinoma with anterior commissure extension is 57–84 % [43, 72– 75]. Local control rates of 80–90 % have been reported after frontolateral partial laryngectomy for T1 carcinomas involving the anterior commissure [76–78]. Mallet et al. [79] achieved a 5-year local control rate of 94 % in 65 patients with T1 and T2 glottic carcinomas who underwent a reconstructive anterior frontal laryngectomy with epiglottoplasty (Tucker operation).

Instead of a frontolateral partial laryngectomy, the more extensive supracricoid partial laryngectomy has been performed at some centers with the intention of improving the local control of anterior commissure disease. The supracricoid partial laryngectomy with cricohyoidoepiglottopexy (SCPL-CHEP) involves the resection of both vocal cords, both ventricular folds, the paraglottic space on both sides, the entire thyroid cartilage, the petiole of the epiglottis, and the lower portion of the preepiglottic fat. For reconstruction, the cricoid cartilage is first attached to the epiglottic remnant and then to the hyoid bone. This operation invariably requires a temporary tracheotomy and nasogastric tube feeding. Laccourreye et al. [80] reported on 62 cases of T1 and T2 glottic carcinomas invading the anterior commissure managed by the SCPL-CHEP operation. Eighty-one percent of the patients received neoadjuvant chemotherapy. The 5-year local control rate was excellent (98 %). None of the patients had to have a laryngectomy or permanent tracheotomy for functional reasons. It should be noted, however, that the treatment is associated with considerable morbidity and therefore cannot be recommended for all patients. All the patients in the Laccourreye series were extubated, but 17 required swallowing training for aspiration, four required temporary percutaneous endoscopic gastrostomy (PEG) tube placement, and one required permanent PEG placement. SCPL-CHEP is followed by an aryepiglottic vocal compensation with correspondingly poor voice quality [81–83].

Conclusion

Comparing the results of different treatments for early carcinoma of the vocal cords, we may conclude that laser microsurgery is the method of choice for the treatment of early glottic carcinoma based on oncologic, functional, and economic considerations. We do not believe that involvement of the anterior commissure is a contraindication against laser surgery, since the local control rates are comparable to that after vertical partial laryngectomy. Excellent local control rates can be obtained with SCPL-CHEP in properly selected patients, but this is achieved at the cost of considerably higher morbidity and frequent, significant impairment of swallowing and phonation.

T2 carcinomas of the glottis comprise a very heterogeneous group of tumors. Some cases may show supraand/or subglottic tumor extension with normal vocal cord mobility, while other lesions cause impaired vocal cord mobility and show considerable supraand/or subglottic extension. The two groups differ markedly in their prognosis. T2 tumors with impaired vocal cord mobility are comparable to T3 tumors with vocal cord fixation from the standpoint of local control rates and survival. We believe, therefore, that it is important to distinguish between T2a and T2b carcinomas. In their proposal for revising the TNM classification, Kleinsasser and Glanz [84] state that glottic carcinomas with impaired vocal cord mobility should be placed in the T3 category along with tumors that cause vocal cord fixation.

Operative Technique

The resection of larger glottic carcinomas by laser microsurgery requires subdividing the tumor into several parts. Tumors that have invaded the paraglottic space are subdivided by incisions extending laterally to the thyroid cartilage and inferiorly to the cricoid cartilage. The resection can be extended to the perichondrium of the thyroid cartilage and cricoid cartilage, to the thyroid and cricoid cartilages themselves, to the arytenoid cartilage, the cricothyroid ligament and the extralaryngeal soft tissues (Figs. 6.6, 6.7).

Fig. 6.6 Technique for resecting an extensive glottic carcinoma. a Incision anterior to the arytenoid cartilage. b Piecemeal tumor resection, proceeding from posterior to anterior. c (Partial) resection of the arytenoid cartilage (diagrams from [4]).

Fig. 6.7 Glottic carcinoma with fixation of the right vocal cord (T3). a Preoperative appearance. b Appearance after resection of the vocal fold, ventricular fold, and arytenoid cartilage by laser microsurgery.

Results of Laser Microsurgery

To date, we have experience with the laser microsurgery of glottic carcinomas causing impaired vocal cord mobility (T2b) or vocal cord fixation (T3) in a total of 167 patients. The postoperative TNM stage was pT2b(p)N0M0 in 97 patients and pT3(p)N0M0 in 70 patients. In patients with pT2b carcinomas, the anterior commissure was involved in 81 % of cases, the contralateral vocal cord in 17 %, the ipsilateral ventricular fold in 58 %, and the infraglottic region in 52 %. In patients with pT3 tumors, the anterior commissure was involved in 70 %, the contralateral vocal cord in 28 %, the ipsilateral ventricular fold in 56 %, and the infraglottic region in 65 %. The arytenoid cartilage was fixed in 45 % of cases. Postoperatively, 10.3 % of patients with stage II disease and 8.6 % of patients with stage III disease underwent radiotherapy. The Kaplan–Meier 5-year local control rate was 74 % for pT2b carcinomas and 68 % for pT3 carcinomas. The respective secondary laryngectomy rates were 13.4 % and 14.3 %. The 5-year rate for definitive local tumor control was 87 % in both groups, and the 5-year recurrencefree survival rate was 62 % in both groups.

Postoperative voice quality in most patients was good. Speech intelligibility in the telephone test following ex-

tended laser resections was better than 90 % in both groups. One patient developed glottic/subglottic cicatricial stenosis, necessitating a permanent tracheotomy. None of the patients was tracheotomized for the primary tumor surgery. Only 11 % of patients with stage II disease and 44 % of patients with stage III disease required nasogastric tube feeding (median of 4 days in the former group, 5 days in the latter). All patients were fully rehabilitated and had unrestricted oral intake. In summary, primary laser microsurgery can achieve a permanent cure in approximately 70 % of patients, with preservation of the larynx and low morbidity [25].

Elsewhere in the literature, very little has been published on the laser microsurgery of T2 or T3 glottic carcinomas. Motta et al. [22] reported on 37 patients with T3 tumors who underwent laser microsurgery. Fifty-five percent of their patients developed locoregional recurrence, and 35 % required salvage by secondary laryngectomy.

Other Treatment Options

The standard treatment for T2 glottic carcinoma with impaired vocal cord mobility is vertical partial laryngectomy or radiotherapy. Local control rates of 52–76 % have been achieved with vertical partial laryngectomy for T2b neoplasms [85, 86]. Total laryngectomy is frequently done for glottic carcinomas with vocal cord fixation, and a few selected cases are managed by hemilaryngectomy. Local control rates between 73 % and 83 % have been reported after partial laryngectomy [87–90]. Primary total laryngectomy with a neck dissection, with or without postoperative irradiation, has a reported locoregional control rate of 69–87 %, a 5-year overall survival rate of 53–56 %, and a disease-spe- cific survival rate of 71–78 % [91–93].

Another organ-conserving treatment option for T2 and selected T3 glottic cancers is SCPL-CHEP, which may be performed without chemotherapy [94, 95] or with neoadjuvant chemotherapy using cisplatin and 5-fluorouracil [96– 98]. Contraindications to this procedure are fixation of the arytenoid cartilage, subglottic tumor extension to the upper border of the cricoid cartilage, infiltration of the cricoid cartilage or thyroid cartilage, extensive infiltration of the preepiglottic space, and extralaryngeal tumor extension [99]. Laccourreye et al. [98] reported in 1999 on 100 patients with T2 glottic carcinoma treated by SCPL-CHEP. Preoperative vocal cord mobility was impaired in 54 % of patients. The anterior commissure was involved in 42 % of cases, and there was infraglottic involvement in 10 %. The patients received three cycles of neoadjuvant chemotherapy with cisplatin and 5-fluorouracil at intervals of 15– 21 days. Complete remission was achieved in 24 % of patients and partial remission in 58 %. The 5-year local control rate was 97.7 % for T2a lesions and 93.8 % for T2b lesions. The larynx was preserved in 95 % of patients. Postoperative aspiration pneumonia developed in 9 % of the patients, and one patient required a laryngectomy for functional reasons. Using the same treatment regimen for glottic carcinoma with vocal cord fixation in 20 patients, Laccourreye and his group achieved a 3-year local control rate of 89.2 % and a larynx preservation rate of 90 % [96]. Chevalier et al.

[94] achieved similar results in 112 patients with glottic carcinoma and impaired vocal cord mobility (n = 90) or vocal cord fixation (n = 22) without the use of neoadjuvant chemotherapy. The 5-year local control rate was 97.3 %, and the 5-year rate for larynx preservation was 95.5 %.

The local control rate after the primary radiotherapy of T2 glottic carcinoma with impaired vocal cord mobility is between 60 % and 76 %, and the rate of organ preservation is 70–80 % [35, 37, 41, 43, 100–102]. Fein et al. [35] achieved a 5-year local control rate of 87 % for T2 glottic carcinoma with normal vocal cord mobility. This rate declined to 76 % when vocal cord mobility was impaired. Five-year local control rates of 30–68 % are reported for the primary radiotherapy of T3 glottic carcinomas, with definitive local control rates of 80–86 %. The 5-year overall survival rate is 51– 59 %. The 5-year rate for larynx preservation is 50–76 % [37, 103–106].

Another organ-preserving treatment concept, currently undergoing clinical trials, is neoadjuvant chemotherapy followed by radiation therapy. The first randomized study to test this regimen was conducted by the Veterans Administration Study Group on Laryngeal Cancer [107, 108]. The patients were randomized into a standard treatment group, consisting of surgery and postoperative radiation, and a study group that received two cycles of chemotherapy followed by surgery and radiotherapy in cases showing persistent or progressive tumor growth. Patients who showed partial or complete remission received a third cycle of chemotherapy followed by radiotherapy. A total of 332 patients with resectable glottic (37 %) or supraglottic (61 %) stage III or IV laryngeal carcinomas (except for T1N1) were randomly assigned to the two treatment groups. After a median follow-up of 98 months, no differences were found between the two groups with regard to local and regional recurrences, distant metastases, and survival rates. The larynx was preserved in 31 % of the patients originally assigned to the study group, representing 66 % of the survivors. On a critical note, it should be added that 9.3 % of the patients had primary tumors of the T1 or T2 category. These tumors could have been treated just as well with a partial laryngectomy using classic or laser microsurgical technique.

In a similar French study conducted by the GETTEC (Groupe d’Etude des Tumeurs de la Tete et du Cou), induction chemotherapy followed by radiotherapy was compared with surgery and postoperative radiation. A total of 68 patients with glottic or supraglottic laryngeal carcinomas with vocal cord fixation (93 % stage III, 7 % stage IV) were randomly assigned to two treatment groups. After 3 years, 20 % of the patients assigned to the chemotherapy group were still alive and still had their larynx. Significantly better diseasefree survival and overall survival were documented in the group that underwent primary laryngectomy [109].

The results of the two studies were different despite similar study design. While survival in both treatment groups was the same in the Veterans Administration study, the survival rates were markedly lower in the group that received neoadjuvant chemotherapy in the French study. The cause may lie in the different patient populations. While

vocal cord fixation was present in only 57 % of the patients in the Veterans Administration study, this condition was an inclusion criterion in the French study.

In another study on larynx preservation with induction chemotherapy and subsequent radiotherapy, the 5-year rate for larynx preservation was 31 % in patients who showed good response to the chemotherapy [110].

Conclusion

The role of laser microsurgery in the treatment of T2b and T3 glottic carcinomas cannot yet be definitively evaluated because data are available from only one institution and have not yet been reproduced elsewhere. Nevertheless, our results published to date indicate that approximately 70 % of patients with pT2b and pT3 carcinomas remain free of local tumor recurrence following primary treatment, with minimal morbidity and a functioning larynx. The results of laser microsurgery for T4 glottic carcinomas have not been presented because adequate data are not yet available. Comparison with the results of vertical partial laryngectomy is difficult because patients are selected for partial laryngectomy on an individual basis and total laryngectomy is already indicated in patients with T2b and T3 tumors. The local control rates achieved with supracricoid partial laryngectomy are excellent. It should be noted, however, that the patients were selected according to the criteria stated, and that this procedure is not appropriate for every patient because of its operative morbidity. In the studies that investigated the possibility of larynx preservation with radiotherapy in selected patients and on the basis of chemotherapy response, the results show that this concept cannot be established as a standard regimen at the present time.

Recurrent Glottic Carcinoma after

Radiotherapy

Approximately one-half of carcinomas recurring after radiotherapy are classified as transglottic T3 or T4 tumors at the time of diagnosis [111]. Recurrences detected early can be managed with a classic partial laryngectomy, but a partial laryngectomy is rarely practiced in this subgroup for fear of postoperative complications such as cartilage necrosis, laryngeal stenosis, fistula formation, aspiration, and delayed extubation. In many cases, total laryngectomy is the only salvage option remaining for recurrent glottic carcinoma after radiotherapy.

Several authors have reported results for small numbers of patients who underwent vertical partial laryngectomy for recurrent T1 and T2 neoplasms [112–116]. Tumors in 13– 24 % of the patients were not controlled by a partial resection, making it necessary to proceed with total laryngectomy. Complications occurred in up to 20 % of cases, consisting mainly of wound healing problems, and intubation had to be continued for several weeks in up to 30 % of the patients. Besides open vertical partial laryngectomy, another option for recurrence after failed radiotherapy is SCPL-

CHEP or SCPL-cricohyoidopexy (SCPL-CHP) [44, 117, 118]. In the series of 12 cases reported by Laccourreye et al. [117], five patients developed complications (perichondritis, stenosis, aspiration pneumonia). The larynx was preserved in three-fourths of the cases.

Partial laryngectomy by laser microsurgery has been described as another alternative to classic partial laryngectomy for T1 and T2 recurrent tumors [119–123]. From 13 % to 53 % of patients had subsequent total laryngectomy, usually after the first failed attempt at laser surgery. The patients who did not develop tumor recurrence were able to swallow without difficulty and were not tracheotomized. Wound healing problems resulting in cartilage loss and stenosis were much less frequent after laser microsurgery in these studies than after classic partial laryngectomy.

We have performed laser microsurgery in a total of 34 patients to treat early and advanced recurrences of glottic carcinoma after radiotherapy. Of these patients, 71 % remained disease-free after one or more laser procedures and retained a functioning larynx. Seven patients (20 %) underwent total laryngectomy, six for a tumor recurrence and one for chondronecrosis. Three patients required a temporary tracheotomy. The 5-year disease-specific survival rate was 86 % [124].

Conclusion

A comparison of the oncologic and functional results reported in the literature shows that laser microsurgery is an acceptable alternative to classic partial laryngectomy for recurrent carcinoma after radiotherapy and is even an alternative to total laryngectomy in selected cases. Laser microsurgery and classic partial laryngectomy are comparable in terms of organ preservation. The complication rates of laser microsurgery are significantly lower than those of classic partial laryngectomy, and its functional results are better.

Steiner has used the CO2 laser for the transoral endoscopic treatment of initially selected patients with supraglottic carcinoma [11, 127]. Davis et al. [128] reported in 1983 on an initial series of 20 patients who underwent laser epiglottectomy for the treatment of benign airway-ob- structing lesions or small suprahyoid epiglottic carcinomas. Davis et al. [129] and Zeitels et al. [130] subsequently reported on additional transoral laser resections in selected patients with supraglottic cancers.

Fig. 6.8 Lines of resection for a supraglottic carcinoma involving the preepiglottic space (diagrams from [4]).

T Laser Microsurgery of Supraglottic

Carcinoma

Supraglottic T1 and T2 Carcinoma

Early supraglottic carcinomas are defined as tumors that have not infiltrated the preepiglottic fat, have not immobilized a vocal cord, and have not yet metastasized to regional lymph nodes. Many laryngologists have shown that supraglottic laryngectomy, first described by J. M. Alonso in 1947 [125], is an effective treatment method for these lesions. Another option for early supraglottic tumors is radiotherapy. Supraglottic laryngectomy is associated with significant morbidity and postoperative functional problems, therefore it is often not an acceptable surgical treatment option, especially in elderly patients with multiple comorbidities and reduced pulmonary function. Vaughan of Boston [126] was the first surgeon to describe the CO2 laser resection of a supraglottic carcinoma. Since 1979,

Fig. 6.9 Lines of resection for a supraglottic carcinoma involving the preand paraglottic spaces (diagrams from [4]).

Fig. 6.10 A supraglottic laryngeal carcinoma infiltrating the preepiglottic space (T3). a Preoperative appearance. b Appearance (inspiratory view) 2 years after tumor resection by laser microsurgery.

Other Treatment Options

The reported oncologic results of classic supraglottic laryngectomy for early supraglottic carcinoma are very good. Local control rates of 90–100 % have been reported for T1 carcinomas and 80–97 % for T2 carcinomas [136–143]. The 5- year survival rates achieved with laser microsurgery are comparable to the rates reported for conventional supraglottic laryngectomy. Several authors have stated 3-year corrected survival rates of 67–92 % for stage I disease and 80–85 % for stage II disease [138, 140, 142–146].

Primary radiotherapy can achieve local control rates of 77– 100 % in supraglottic T1 cancers and 62–83 % in T2 cancers [147–153]. While Inoue et al. [149] obtained significantly better local control rates for tumors of the epilarynx than

The first results in 36 patients treated by laser microsurgery were presented in 1985 and published by Steiner and Herbst in 1987 [188]. These were followed by a report on 42 patients treated at the Department of Otorhinolaryngology of Erlangen-Nuremberg University Hospital between 1981 and 1986 [184]. Several more studies were published

Fig. 6.11 Lines of resection for hypopharyngeal carcinoma. a Carcinoma of the aryepiglottic fold. b Carcinoma of the medial, anterior, and lateral walls of the piriform sinus. c Piriform sinus completely filled by carcinoma. d Carcinoma of the aryepiglottic fold with possible infiltration of the arytenoid cartilage. e Carcinoma of the postcricoid region. f Carcinoma of the piriform sinus with involvement of the oropharynx. g Carcinoma of the piriform sinus with involvement of the postcricoid region and posterior wall of the hypopharynx (diagrams from [4]).