The Utility of Second Look Microlaryngoscopy after Trans Oral Laser Resection of Laryngeal Cancer

Abstract

In the past few decades more and more number of tumors of the glottis and supraglottis are been treated with single stage transoral laser microsurgery (TOLS). TOLS for the treatment of glottic and supraglottic carcinoma with anterior commissure (A-com) and/paraglottic space involvement is associated with a high rate of recurrence. We prospectively evaluated the outcomes of laser microsurgery and the impact of second look operation in these patients. Twenty-three patients with glottic and supraglottic carcinoma underwent transoral laser micro resection of the lesions. Subsequently five patients underwent second look microlaryngeal evaluation 6-8 months later for non-satisfactory healing, poor voice, and or suspicion of recurrent disease. Patients with A-com involvement and or paraglottic space involvement were followed up longitudinally for the effectiveness and timing of second look microsurgery. After initial transoral laser micro resection, all patients achieved microscopically clear resection margins. At second look microlaryngeal evaluation, local recurrence was found in four of 23 patients. Of these, two patients were salvaged by second look surgery and are disease free, whereas in two others, the larynx had to be subjected to open surgical intervention. One of two had extensive local recurrent tumor and underwent total laryngectomy with neck dissection followed by postoperative radiotherapy. Tracheohyoidopexy was done with successful functional and oncologic outcome for another patient who had local recurrence for the third time. Only the patient who underwent total laryngectomy with neck dissection was subjected to adjuvant post-operative radiotherapy. Finally, larynx was saved in 21 out of 23 patients.

Salvage transoral laser microsurgery for recurrent glottic carcinoma after primary laser-assisted treatment: Analysis of prognostic factors

“…21,22 Others have reported low rates of recurrence 14 and persistent disease (<20%) in patients with pathologically positive margins. 23,24 Surgical revision or open partial horizontal laryngectomy should nonetheless be considered in the case of positive deep surgical margins. 14,22 Judging from the present series of salvage TLM, our results support the conviction that patients with positive deep margins have a higher second recurrence rate and a shorter DFS after salvage treatment (p 5 .05 and p 5 .03, respectively; see Figure 3), whereas positive superficial margins did not correlate significantly with either further recurrence or a shorter DFS, and we suppose this could be due to laser photocoagulation performed on superficial margins.…”

“…Some authors have said that revision surgery is essential after primary TLM with close or positive margins because these conditions predispose to a higher recurrence rate . Others have reported low rates of recurrence and persistent disease (<20%) in patients with pathologically positive margins . Surgical revision or open partial horizontal laryngectomy should nonetheless be considered in the case of positive deep surgical margins .…”

Impact of resection margin status and revision transoral laser microsurgery in early glottic cancer: analysis of organ preservation and local disease control on a cohort of 153 patients

“…Moreover the histopathologic evaluation of surgical margin status represents a main issue with TLM and radical oncological excision; in fact, shrinking of margins during histologic preparation, thermal damage caused by CO 2 laser beam and specimen orientation due to small size are the main causes of problematic surgical margin assessment, ensuing different managements in the postoperative period. 2 , 6 , 7 , 8 , 9 Furthermore, to date there is not agreement on safe resection margin in order to define them as close and/or positive. 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 …”

Retrospective analysis of risk factors for lymph node metastasis in recurrent glottic cancer after primary laser surgery: a cohort study from China

“…This provides further support that the extent of the primary lesion may have a strong effect on neck metastasis. For recurrent cases, there could be undetectable residual tumor cells after the first treatment (23,24). We hypothesized that, due to the deficiency of barriers within the larynx after type V cordectomy, the residual tumor cells might result in local relapse and a high risk of neck metastases (up to 60%) through the accessible lymphatics.…”