Laser surgery of T1a glottic carcinomas; significance of resection margins

Abstract

Since 1995 patients with T1a glottic carcinomas have been treated with laser surgery at the Department of Otorhinolaryngology, Rikshospitalet in Oslo. During this period we have in many cases noticed an inconsistency between the clinical outcome and the histopathological report describing that the resection margins were not free. We wanted to investigate this discrepancy, and the charts with the histopathological reports of 171 patients treated between 1995 and 2005 have been reviewed. Seventeen patients (10%) experienced a recurrence of the initial disease and were treated by repeated laser surgery, radiotherapy, or radiotherapy and laryngectomy. Two patients (1%) had died from the disease. In 36% of the cases (62 patients) the histopathological report indicated "not free" or "probably not free" resection margins. The discrepancy between the histopathological reports and the clinical outcome reflects the pathologist's difficulty in orienting and determining resection margins in laser-resected specimens. Because of the low number of recurrences or metastases, the verdict of a violated resection margin should probably not be crucial for further treatment. The surgeon's peroperative judgement may be trusted, however, with very close follow-up in order to detect early recurrences.

Glottic laser surgery: outcomes according to 2007 ELS classification

“…In our series, the free margins of resection seem to have an impact on recurrent rates and DFS. This is a debated topic without international agreement [16][17][18]. In laser endoscopic surgery, the operator skills play a crucial role in the achieved oncologic results, probably more than in other approaches.…”

Evaluation of surgical margin status in patients with early glottic cancer (Tis-T2) treated with transoral CO2 laser microsurgery, on local control

“…Moreover, as the glottic area reveals symptoms earlier than other areas, enabling earlier detection by patients themselves they will visit their physicians outside the protocol if they experience symptoms. Later authors have also adopted this point of view [10, 22, 29]. In line with these aforementioned arguments, if following a wait-and-see policy, it is necessary to have compliant patients who will be available for follow-up by rigid or flexible endoscopy with stroboscopy combined with additional imaging techniques, such as narrow-band imaging.…”

“…Therefore, it is not uncommon to find close or positive margins during final pathology examination [7, 12]. Currently, literature still shows no clear definition of negative, close or positive surgical margins [13] and recommendations for free margins vary from 0.5 to 2 mm [7, 8, 10, 11, 14–17]. Moreover, controversy remains over the interpretation of surgical margins because of difficulties with orientation after piecemealing, the small size of the specimens, tissue retraction as a result of thermal energy on elastic fibres, thermal damage, and charring.…”

“…However, others conclude that positive margins have no influence on local control [8, 10, 11, 16]. Therefore, the best management of close or positive margins has not been clearly determined [13] although it has been shown that mandatory retreatment could lead to unnecessary additional treatment in up to 84% of these patients [11].…”

“…Therefore, the best management of close or positive margins has not been clearly determined [13] although it has been shown that mandatory retreatment could lead to unnecessary additional treatment in up to 84% of these patients [11]. Therefore, a wait-and-see policy could also be considered appropriate restricting the number of needless procedures performed [10]. According to the latest ELS recommendation for follow-up of laryngeal cancer, a second-look microsurgery is however mandatory in cases of positive surgical margins [21].…”