Abstract
Purpose
The aim of the present paper was to investigate the oncological safety of two-stage bilateral cordectomy for the treatment of cT1b glottic SCC, and to compare its oncological outcome and synechia development rate with those of single-stage procedures.
Materials and methods
A retrospective cohort study was performed at the Otolaryngology Unit of Vittorio Veneto Laryngeal Cancer Center (Italy). The prognostic significance of clinical, pathological and surgical factors was also investigated, in terms of recurrence rate and disease-free survival, in a univariate statistical setting.
Results
Our results indicate that patients treated with primary two-stage bilateral cordectomy achieved local control in 96% of cases, with 95% disease-specific and 88% overall survival rates, and a 95% organ preservation rate, with anterior synechiae developing in 1 case. Involvement of the deep surgical margins correlated with a worse prognosis. Patients developed anterior synechiae less frequently after two-stage bilateral cordectomy, and experienced no higher recurrence rate or shorter disease-free survival than patients treated with a single-stage procedure.
Conclusions
Two-stage bilateral cordectomy is a safe and effective procedure. In selected patients it could be considered the primary approach for the treatment of early glottic cT1b carcinomas.
1
Introduction
According to the current TNM staging system , a glottic squamous cell carcinoma (SCC) is classified as cT1b when it involves both vocal cords without impairing vocal cord mobility or extending to other laryngeal subsites. Although this is considered an early-stage cancer, the clinical efficacy of current treatments is generally unsatisfactory . Treatments for cT1b glottic SCC include transoral laser microsurgery (TLM), radiation therapy (RT), and open partial horizontal laryngectomy (OPHL) . Among the surgical approaches, TLM has gained increasing numbers of supporters in recent years, becoming the standard of care for primary early glottic SCC, while the use of open partial laryngectomy as a first approach to this disease has declined . The currently available literature on the topic suggests that the local control rate after TLM is comparable with the results achieved with RT , while overall survival (OS) and ultimate larynx preservation rates are higher for patients initially treated with TLM than for those treated with primary RT . In the case of cT1b tumors, however, the functional outcome – in terms of phonation – seems to be better for patients treated with RT than for those undergoing TLM . Patients with tumors involving the anterior commissure treated with TLM carry a significant risk of developing anterior synechiae. Two-stage bilateral cordectomy for cT1b glottic carcinoma consists of TLM performed in two steps with a view to reducing the risk of anterior synechiae without affecting oncological radicality. The Göttingen school was the first to advocate a two-stage bilateral cordectomy to limit the risk of anterior synechia. There is still a shortage of information on the topic, however, and – to the best of our knowledge – this is the first paper to investigate the oncological validity of two-stage cordectomy.
The main endpoint of the present study was to investigate the oncological safety of two-stage bilateral cordectomy for the treatment of cT1b glottic SCC, and to compare the related postoperative synechia development rate with that associated with one-stage surgery. A second endpoint was to identify potential clinical and/or pathological prognostic factors in order to pinpoint patients at higher risk of recurrence after primary TLM.
2
Materials and methods
2.1
Patients, inclusion criteria, equipment and technique
Between 2000 and 2012, we performed 542 TLM procedures for early laryngeal carcinoma at the Otolaryngology Unit of Vittorio Veneto Laryngeal Cancer Center (Italy). The present study retrospectively considered 92 patients who underwent TLM for cT1b glottic SCC with anterior commissure involvement. Primary tumors were staged according to the current classification of the Union Internationale Contre le Cancer and the American Joint Committee on Cancer . Primary laser cordectomies were performed and archived according to the 2007 revised European Laryngological Society (ELS) classification . TLM was not indicated for cT1b glottic SCC patients with an unsatisfactory exposure of the glottis; OPHL was preferred in such cases.
A laser-assisted two-stage bilateral cordectomy was performed in cases of primary cT1b glottic SCC, not for primary tumors of the anterior commissure. Fig. 1 shows the steps involved in the procedure. The first stage consisted of a cordectomy on the side of the main lesion, which was extended to the anterior commissure. In the second stage, the contralateral cordectomy was again extended to the anterior commissure to include the previous anterior resection margin. The second stage was usually scheduled 30 days after the first to allow for complete re-epithelization of the previously-treated vocal cord . The surgical specimen was marked with blue ink along the posterior margin and submitted for pathological examination. In their assessment of the resection margins in the case of two-stage procedures, the pathologists were asked to consider only the status of the deep margins in order to avoid any bias due to the involvement of the anterior superficial margin. The margins were classified as negative, close (< 1 mm), positive, or with artifacts.
A single-stage procedure was preferred for elderly patients without phonation needs or at higher anesthesiological risk, and for patients who had difficulty coming to our clinic.
From 2007 onwards, all laser cordectomies were followed by endoscopic photocoagulation of the superficial resection margins . A strict follow-up was adopted, with monthly endoscopies for at least a year, in cases with superficial margin involvement (single-stage procedures) (1), or close deep margins (2), or artifacts on margins (3). A second-look TLM was scheduled for patients with deep margin involvement.
TLM was performed under general anesthesia after orotracheal intubation in all patients. The larynx was exposed with various laryngoscopes, a Bouchayer-Microfrance type laryngoscope (Xomed, USA) being the most frequently used. The Mallampati and Cormack-Lehane scales were used to quantify the quality of the exposure. A Leica M520 F40 microscope (Leica Microsystems, Heerbrugg, Switzerland) coupled with an Ultra Pulse Surgitouch and an Acuspot 712 micromanipulator (Lumenis Ltd., Yokneam, Israel) were used to complete the procedure. All CO 2 -laser-assisted endoscopic resections were performed by the same surgical team (M.Lu. and A.B.)
2.2
Voice assessment
Voice quality was measured subjectively by patients using the Voice Handicap Index (VHI) , and a perceptual voice assessment (GIRBAS scale) . The VHI assesses patients’ subjective perception of disability due to their vocal dysfunction. It consists of 3 subscales – emotional, physical, and functional – and generates a total score (range 0–120 points) and subscale scores (range 0–40): the higher the score, the greater the voice handicap. The VHI scores were grouped into 5 different categories: 0 (normal voice), 1 to 30 (mild dysphonia), 31 to 60 (moderate dysphonia), 61 to 90 (severe dysphonia), and 91 to 120 (very severe dysphonia). The perceptual voice assessment was conducted by an otolaryngologist blinded to the patient’s treatment, who graded the voice on the GIRBAS scale, which covers 5 domains: grade (G), instability (I), roughness (R), breathiness (B), asthenicity (A), and strain (S). Each patient was rated in all 5 domains on a scale from 0 to 3, where 0 corresponded to a normal voice, 1 to a mild voice problem, 2 a moderate problem, and 3 to a severe problem.
2.3
Statistical analysis
For the univariate analysis, Fisher’s exact test was used to calculate recurrence rates (RR), while the log-rank test and the Kaplan-Meier survival function were used to calculate the different disease-free survival (DFS) intervals (in months) for patients stratified according to their clinical-pathological and surgical variables. The χ 2 test and the Mann-Whitney U test were used to compare survival and functional outcomes, respectively. A p -value < 0.05 was considered significant. The STATA™ statistical package (Stata Corp, College Station, TX, USA) was used for all analyses.
2
Materials and methods
2.1
Patients, inclusion criteria, equipment and technique
Between 2000 and 2012, we performed 542 TLM procedures for early laryngeal carcinoma at the Otolaryngology Unit of Vittorio Veneto Laryngeal Cancer Center (Italy). The present study retrospectively considered 92 patients who underwent TLM for cT1b glottic SCC with anterior commissure involvement. Primary tumors were staged according to the current classification of the Union Internationale Contre le Cancer and the American Joint Committee on Cancer . Primary laser cordectomies were performed and archived according to the 2007 revised European Laryngological Society (ELS) classification . TLM was not indicated for cT1b glottic SCC patients with an unsatisfactory exposure of the glottis; OPHL was preferred in such cases.
A laser-assisted two-stage bilateral cordectomy was performed in cases of primary cT1b glottic SCC, not for primary tumors of the anterior commissure. Fig. 1 shows the steps involved in the procedure. The first stage consisted of a cordectomy on the side of the main lesion, which was extended to the anterior commissure. In the second stage, the contralateral cordectomy was again extended to the anterior commissure to include the previous anterior resection margin. The second stage was usually scheduled 30 days after the first to allow for complete re-epithelization of the previously-treated vocal cord . The surgical specimen was marked with blue ink along the posterior margin and submitted for pathological examination. In their assessment of the resection margins in the case of two-stage procedures, the pathologists were asked to consider only the status of the deep margins in order to avoid any bias due to the involvement of the anterior superficial margin. The margins were classified as negative, close (< 1 mm), positive, or with artifacts.
A single-stage procedure was preferred for elderly patients without phonation needs or at higher anesthesiological risk, and for patients who had difficulty coming to our clinic.
From 2007 onwards, all laser cordectomies were followed by endoscopic photocoagulation of the superficial resection margins . A strict follow-up was adopted, with monthly endoscopies for at least a year, in cases with superficial margin involvement (single-stage procedures) (1), or close deep margins (2), or artifacts on margins (3). A second-look TLM was scheduled for patients with deep margin involvement.
TLM was performed under general anesthesia after orotracheal intubation in all patients. The larynx was exposed with various laryngoscopes, a Bouchayer-Microfrance type laryngoscope (Xomed, USA) being the most frequently used. The Mallampati and Cormack-Lehane scales were used to quantify the quality of the exposure. A Leica M520 F40 microscope (Leica Microsystems, Heerbrugg, Switzerland) coupled with an Ultra Pulse Surgitouch and an Acuspot 712 micromanipulator (Lumenis Ltd., Yokneam, Israel) were used to complete the procedure. All CO 2 -laser-assisted endoscopic resections were performed by the same surgical team (M.Lu. and A.B.)
2.2
Voice assessment
Voice quality was measured subjectively by patients using the Voice Handicap Index (VHI) , and a perceptual voice assessment (GIRBAS scale) . The VHI assesses patients’ subjective perception of disability due to their vocal dysfunction. It consists of 3 subscales – emotional, physical, and functional – and generates a total score (range 0–120 points) and subscale scores (range 0–40): the higher the score, the greater the voice handicap. The VHI scores were grouped into 5 different categories: 0 (normal voice), 1 to 30 (mild dysphonia), 31 to 60 (moderate dysphonia), 61 to 90 (severe dysphonia), and 91 to 120 (very severe dysphonia). The perceptual voice assessment was conducted by an otolaryngologist blinded to the patient’s treatment, who graded the voice on the GIRBAS scale, which covers 5 domains: grade (G), instability (I), roughness (R), breathiness (B), asthenicity (A), and strain (S). Each patient was rated in all 5 domains on a scale from 0 to 3, where 0 corresponded to a normal voice, 1 to a mild voice problem, 2 a moderate problem, and 3 to a severe problem.
2.3
Statistical analysis
For the univariate analysis, Fisher’s exact test was used to calculate recurrence rates (RR), while the log-rank test and the Kaplan-Meier survival function were used to calculate the different disease-free survival (DFS) intervals (in months) for patients stratified according to their clinical-pathological and surgical variables. The χ 2 test and the Mann-Whitney U test were used to compare survival and functional outcomes, respectively. A p -value < 0.05 was considered significant. The STATA™ statistical package (Stata Corp, College Station, TX, USA) was used for all analyses.
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