13-cis-Retinoic acid has been reported to be effective in treating oral leukoplakia. We randomly assigned 44 patients with this disease to receive 13-cis-retinoic acid (24 patients) or placebo (20), 1 to 2 mg per kilogram of body weight per day for three months, and followed them for six months. There were major decreases in the size of the lesions in 67 percent (16 patients) of those given the drug and in 10 percent (2 patients) of those given placebo (P = 0.0002); dysplasia was reversed in 54 percent (13 patients) of the drug group and in 10 percent (2 patients) of the placebo group (P = 0.01). The clinical response to the drug correlated with the histologic response in 56 percent (9 of 16) of the patients evaluated. Relapse occurred in 9 of 16 patients two to three months after treatment ended. The toxic effects of the drug were acceptable in all but two patients. Cheilitis, facial erythema, and dryness and peeling of the skin were common; conjunctivitis and hypertriglyceridemia also occurred. All adverse reactions could be reversed by reducing the dose or temporarily discontinuing the drug. We conclude that 13-cis-retinoic acid, even in short-term use, appears to be an effective treatment for oral leukoplakia and has an acceptable level of toxicity.

Stenosis of the larynx and/or trachea presents perplexing problems. No one technique has proved totally satisfactory in the management of all varieties of stenosis. Recent reports have described the successful use of the CO2 laser in the endoscopic management of stenosis of the larynx and trachea. Failures of this technique need emphasis to assure appropriate selection of therapeutic method. Retrospectively, 49 cases of laryngeal stenosis, 6 cases of tracheal stenosis and 5 cases of combined laryngeal and tracheal stenosis were studied (total 60 patients) following treatment at the Boston University Affiliated Hospitals. Follow-up ranged from 1 to 8 years. Multiple procedures were required in 35 laryngeal patients. Of the laryngeal patients 39 were successfully managed (average number of procedures in successful cases 2.18). Of 11 tracheal patients with combined laryngeal and tracheal procedures, 3 were successfully managed (average number of procedures in successful cases 6). Failures in laryngeal stenosis included four patients in whom an adequate airway was not established though voice was present while maintaining tracheostomies. Thirteen patients failing endoscopic management required open surgery with good result. Factors associated with poor result or failure include circumferential scarring with cicatricial contracture, scarring wider than 1 cm in vertical dimension, tracheomalacia and loss of cartilage, previous history of severe bacterial infection associated with tracheostomy, and posterior laryngeal inlet scarring with arytenoid fixation. In these circumstances, multiple procedures, more extensive alternative open surgical techniques, or maintenance of tracheostomy were necessary. In successful cases only three or fewer procedures on average were required. The factors associated with failure or success of endoscopic methods in the management of laryngotracheal stenosis, including use of the CO2 laser and soft Silastic stents, are analyzed.

The sequence of histological change induced by CO2 laser irradiation was discussed in terms of two factors: the physiomechanical factor and the physiochemical factor. At sufficiently high heat energy levels, the immediate findings are characterized by crater formation resulting from rapid vaporization of the water and ejection of the solid component. In the immediate vicinity of the crater edge, the maximum tissue temperature rise is 65 degrees C above the 32 degrees C ambient tissue temperature and it decreases to the primary tissue temperature within a distance of 2 mm. The healing process of CO2 laser induced lesions proceeds with minimal delay. The lymphatic and vascular channels are occluded in the marginal area of coagulation resulting in a marked hemostatic effect. This sealing effect increases the margin of safety in preventing possible dissemination of tumor cells. By selecting the appropriate power, time, and focus cone angle, precise destruction of preselected areas of tissue can be achieved with an extraordinary hemostatic effect without damaging the underlying tissue. These advantages are especially helpful in function-preserving surgery.

Transoral excisional biopsy has been used in the evaluation and management of 103 T1 glottic cancers. A 3-year follow-up on these patients indicates that excisional biopsy unequivocally established the diagnosis and stage of the disease and that it is adequate treatment for micro and mini squamous cell cancers of the glottis in which the margins of excision are clear. Excisional biopsy with positive margins and larger T1 tumors establishes the absolute need for radiotherapy. Excisional biopsy is ideal for the diagnosis and management of verrucous carcinoma and spindle cell carcinoma. Recurrent/residual squamous cell carcinoma after radiotherapy should be explored by excisional biopsy which may be curative or will establish the need for partial or total laryngectomy. The appropriate use of excisional biopsy in the selective management of early T1 glottic cancers requires attention to detail by the surgeon and the pathologist and sound clinical judgment.

Transoral excision of supraglottic and hypopharynx cancer as a single modality is effective when lesions are selected for small size and endoscopic accessibility. Excisional biopsy with clear margins of larger supraglottic tumors in combination with postoperative radiotherapy provides an excellent treatment alternative for selected lesions in patients who are not candidates for open surgery. In this preliminary report, 45 cases using this minimally invasive approach are reviewed outlining oncologic rationale and functional advantages. A large bore tubed laryngoscope or the adjustable bivalve supraglottiscope was used along with a carbon dioxide laser in all cases. In 22 of the 45 patients (mostly TI), local en bloc excision of the primary cancer was performed as sole treatment on selected lesions of the supraglottis and hypopharynx. There were no local recurrences, however, 1 patient developed a neck recurrence and was salvaged by neck dissection. Twenty‐three of the 45 patients had more extensive primaries (mostly T2, T3) and N0 necks. Transoral excisional biopsy was followed by full‐course radiation therapy to the primary site and both necks. All 23 were followed a minimum of 2 years, and the median follow‐up period was 58 months. Clear margins were obtained in 16 of 23, and there were no recurrences in the larynx. Two of 16 did fail in the neck and died despite neck dissection. Seven of 23 patients had positive margins and, despite full‐course radiotherapy to the primary site and both necks, 5 of 7 failed locally or regionally. Two of the 7 died of their disease despite open salvage surgery. Therefore, 4 of 23 patients who underwent transoral excision of larger lesions followed by full‐course radiotherapy died of recurrent cancer.