Endoscopic Laser Surgery An Alternative in W. Frederick

Laryngeal Cancer Treatment

McGuirt, MD, James A. Koufman, MD

\s=b\ Thirty-three patients with newly diagnosed laryngeal carcinoma underwent endoscopic treatment with the carbon dioxide laser under microscopic control and venturi jet ventilation. Ten of these patients underwent emergency tumor debulking to relieve airway obstruction and to avoid emergency tracheotomy for airway control, and 23 had definitive treatment of superficial or frankly invasive carcinoma. Among the first group, all had an adequate airway after tumor debulking and could be treated with elective laryngectomy with or without radical neck dissection once their metabolic conditions had improved and they had been appropriately evaluated. Among the second group, two died of lung carcinoma but were free of laryngeal disease and two were lost to followup at one year. With a minimal three-year follow-up, six of the remaining 19 patients underwent additional laser procedures. None have required external laryngeal surgery or radiation therapy. Endoscopic laser therapy appears preferable to a more radical approach for carcinoma in situ, microinvasive carcinoma, or superficially invasive carcinoma of the larynx. (Arch Otolaryngol Head Neck Surg

1987;113:501-505) Accepted for publication Dec 1, 1986.

Otolaryngology, Department of Surgery, Wake Forest University Medical Center, Bowman Gray School of Medicine, Winston-Salem, NC. Presented at the University of Iowa Alumni Reunion honoring Brian F. McCabe's 25th anniversary as Chairman of the Department of Otolaryngology, Iowa City, Iowa, May 9, 1986. Reprint requests to Section of Otolaryngology, Bowman Gray School of Medicine, 300 S Hawthorne Rd, Winston-Salem, NC 27103 (Dr From the Section

McGuirt).

on

dioxide laser, with Thegreatcarbon added sig¬ precision, dimension the its

has

a

nificant to surgical treatment of laryngeal and upper air¬ way disorders. Combining use of the

carbon dioxide laser, the operating microscope with its improved visual¬ ization and magnification, and ventu¬ ri jet ventilation with its capability of maintaining anesthesia without a visually obstructing tube provides a triad of tools that has greatly advanced endolaryngeal surgery. Most of the early literature on the carbon dioxide laser dealt with its use in the treatment of papillomas, con¬ genital and acquired upper airway stenoses, and benign mass lesions of the larynx.1-2 Few articles discussed its use for neoplastic conditions.34 Lynch,5 in 1920, was the first to introduce the transoral route for treating laryngeal carcinoma. Using that approach, New and Dorton6 reported 90% cure rates with diather¬ my excision in 1940. Interest in the approach lagged thereafter until 1973, when it was rekindled by Lillie and DeSanto's7 report of 98 patients who had transoral, endoscopically treated carcinomas, 93 of whom were alive and seemingly tumor-free at five years

(94.9% five-year

cure

rate).

Over the next decade, Vaughan et al,8 Strong and Jako,9 and Davis et al10 further expanded the capabilities of transorai endoscopie microscopic la¬ ryngeal cancer surgery by using the laser as the cutting tool, a method

that

provided them with

a

much

greater degree of precision than had

been possible before. They also dem¬ onstrated the laser's usefulness in securing a safe airway without resort¬ ing to tracheotomy, with its adverse implications in obstructive laryngeal lesions.10 However, the roles and the advantages of these techniques in the treatment of laryngeal carcinomas are still often unappreciated; thus the techniques are underused. In this arti¬ cle, we share our experience in treat¬ ing laryngeal carcinoma with the car¬ bon dioxide laser in the hope that it will encourage greater use of this

technique. PATIENTS AND METHODS From 1979 through 1984, 287 patients with laryngeal carcinoma were seen at the Wake Forest University Medical Center, Winston-Salem, NC, for the first time. Of those, 33 (11%) had laser therapy as part or all of their definitive treatment. Ten patients underwent tumor debulking (group A), and 23 patients underwent definitive endoscopie resection for Tl car¬ cinoma (group B). Among the latter group, two patients had carcinoma in situ only (group B-l); seven had carcinoma in situ

with areas of microinvasion (group B-2); and 14 had frankly invasive squamous car¬ cinoma (group B-3).

Group A Any patient having an obstructive laryn¬ geal lesion causing stridor (and often retractions) was placed on respiratory sup¬ port of high-flow oxygen mist and nebu¬ lized micronephrine; intravenous lines were secured through which decadron (20

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Fig 1.—Laser mucosal dissection and vapor¬ ization of

superficial multifocal lesions.

Fig 2.—Wide marginal resection of vocal cord for invasive squamous cell carcinoma.

mg) was given; the patient was taken immediately to the operating room. Respi¬ to 30

ratory support and observation

were con¬

tinued until the venturi jet anesthesia, the laryngoscopic and bronchoscopic equip¬ ment, and a tracheostomy set were ready. The patient was then anesthetized, the venturi side arm laryngoscope was intro¬ duced, and the patient was ventilated. Under control of the operating microscope, the laser was then used to open the airway progressively by vaporizing tumor tissue. The patient's chest movements and arteri¬ al blood gases were monitored. (Koufman et al" have documented adequate oxygen-

ation when venturi jet anesthetic methods are used, as long as a patient is able to move any air voluntarily.) After the air¬ way was satisfactorily opened by debulk¬ ing, biopsy specimens were taken and the patient was awakened. After appropriate evaluation and counseling, each patient then underwent definitive therapy, ie, lar¬ yngectomy with or without concomitant radical neck dissection. It should be noted that this technique of venturi jet ventilation was only used for true glottic and subglottic lesions. Supra¬ glottic lesions frequently required place¬ ment of a foil-wrapped, red rubber tube

before the laser was used to facilitate exposure and maintain the airway simul¬

taneously. Group patients in groups B-l and B-2, therapy consisted of vocal cord stripping by laser mucosal dissection, with vaporiza¬ tion of any adjacent mucosa that appeared abnormal through the operating micro¬ scope, followed by deep laser vaporization of the underlying subcutaneous, fibrous, and muscle tissues as indicated. The depth of vaporization in this group of patients was usually superficial, being determined For

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Fig 3.—Laser cordectomy for deeply invasive carcinoma sparing vocal process and anterior commissure.

by the microscopic appearance of normal underlying tissue. The normal architecture of the cords could usually be maintained in this manner (Fig 1). Patients in these groups had at least

one

microscopic-direct laryngoscopic follow-up study. If abnormal tissue was seen, a biop¬ sy was performed or the cord was restripped and the surrounding tissue and base were treated again with the carbon dioxide laser. When only normal tissues were seen, the patient was followed up thereafter by indirect laryngoscope as appropriate.

Patients in group B-3 with invasive squamous cell carcinoma fit the criteria for endoscopie laser resection if the aryte¬ noid was uninvolved and the anterior com¬ missure was free of disease. These patients received a wide local resection of the mem¬ branous cord and underlying vocal muscle. The depth of resection depended on the extent and depth of tumor; in the simplest case of an isolated free-margin lesion, only a "discectomy" or marginal resection of the cord was necessary (Fig 2); more exten¬ sive and infiltrative lesions required a more radical complete cordectomy down to the thyroid cartilage (Fig. 3). Again, the resection was controlled by the microscop¬ ic appearance of tissue being lased, the depth of resection being carried down to normal-appearing, palpably soft muscle. After the initial resection, specimens were obtained with microcup forceps and sent for frozen-section examination. These patients had repeated microscop¬ ic-direct laryngoscopic follow-up after a period of healing and remodeling. Biopsy specimens were taken from any abnormalappearing areas present thereafter, and

again treated with the laser. Any concomi¬ tant dysplastic or keratotic areas scattered about the laryngeal mucosa were treated as

well.

Groups All patients were actively encouraged to stop smoking. All

RESULTS

Of the ten patients with initially obstructing carcinoma (group A), three died of their primary disease;

free of disease less than 18 months after operation; two were free of disease 25 and 30 months after operation; and four patients had no evidence of disease more than three years after operation. No patient has shown evidence of stornai recurrence after undergoing elective laryngecto¬ my following initial laser tumor debulking and airway maintenance. Of the group patients, two were free of disease when they became unavailable for follow-up at about one year, and two died of primary carcino¬ mas of the lung that had been present at the time of their endoscopie laser resections. Both were clinically free of laryngeal carcinoma at the time of death. The other 19 patients are still under observation. Over a three-year minimal follow-up, none of the 19 patients required either external laryngeal surgery or full-course radi¬ ation therapy for recurrent disease. one was

Among the nine patients assigned B-2, three required one additional laryngoscopic laser to groups B-l and

procedure and two required two addi¬ tional laryngoscopic laser procedures after the initial microscopic-direct laryngoscopic follow-up examination. These additional procedures were required to treat persistent or previ¬ ously untreated areas of dysplastic

or microin¬ vasive carcinoma. Retreatment was usually necessary because the diffuse involvement of the keratosis and dys¬ plasia had prevented complete initial resection, rather than because there was localized recurrence at the initial treatment site. Maintenance of a mucosal surface on one side of the anterior commissure to prevent web formation and to aid voice quality also required laser therapy to the initially untreated side. Among the 14 patients assigned to group B-3, three required a second laryngoscopic laser procedure for abnormal-appearing tissue; two of these patients proved to have granulo¬ mas from delayed healing, and the third patient had carcinoma in situ in an area adjacent to the margin of the original resection. Persistent attempts to persuade the

tissue, carcinoma in situ,

patients to stop smoking were over successful, with only one patient not complying. This patient is among

90%

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those in group B-2

subsequent

having

had two

treatments.

COMMENT

Tumor bulk, cord fixation, and increased secretions jeopardize the airway of the patient with laryngeal carcinoma. Laser debulking, to pro¬ vide a patent airway, both avoids an indwelling tracheostomy tube with its attendant risk of parastomal recur¬ rence12 and allows time for orderly workup for extent of disease, nutri¬ tional rehabilitation to decrease com¬ plications, control of inflammatory processes, and counseling on voice rehabilitation. The use of venturi jet ventilation is the key to the success of this proce¬ dure. As long as the patient's airway is not totally obstructed, venturi jet ventilation provides adequate oxygén¬ ation and ventilation while the debulking is being done with the laser. The postoperative bleeding, rebound edema, and obstruction that result from emergency endotracheal intuba¬ tion and debulking with cup forceps are avoided with this approach. At the opposite end of the spectrum of cancer involvement, laser resection permits extension of conservative laryngeal surgery in the management of small, isolated Tl lesions not affecting cord mobility. The criteria for endoscopie excision of these Tl lesions are similar to those for exter¬ nal conservative laryngeal surgery and those first advocated by Lynch5 for endoscopie therapy of laryngeal carcinoma. The patient should have a mobile cord; the tumor should be lim¬ ited to one anatomic site; and there should be no evidence of cartilaginous invasion. Involvement of the anterior commissure remains difficult to treat, due to the limited depth of resection allowed by the thyroid cartilage and the difficulty in preserving sufficient mucosa for good vocal results. Davis et al" delineated the anatomic limita¬ tions of the laser cordectomy. Until a surgeon has gained extensive experi¬ ence, he or she should not treat lesions of the anterior commissure or paraarytenoid musculature areas with the laser, but should still consider them best treated by external partial laryn¬ gectomy with resection of a block of

cartilage margin and/or arytenoidec¬ tomy. Only the most senior, experi¬

enced laser surgeons should attempt laser resection in these areas. Those few qualified laser surgeons who do deal with anterior commissure and the larger cordal lesions often use this procedure as a staging tool to better identify invasion of cartilage. This better defines the advanced-stage laryngeal carcinoma that frequently is understaged as a Tl lesion. Assessment of tumor size and depth of involvement is excellent when the operating microscope and palpating probes are used. With these tools, a local resection can be carried out, followed by frozen-section biopsies from the margins to assure control of disease. The advantages of this meth¬ od for the Tl carcinomas are: 1. The expeditious nature of the procedure. Although the procedure may be done as an outpatient proce¬ dure, it usually requires hospitaliza¬ tion. However, the duration of hospi¬ talization is only two days, as opposed to eight to ten days required for an open surgical procedure or six weeks of outpatient clinic visits required for radiation therapy. 2. A reduction of morbidity. Pain is minimal and the patient begins oral feeding on the night of the operation. A tracheostomy is obviated. 3. Improved cost effectiveness re¬ sulting from the shortened hospital stay and the usually reduced operat¬ ing time. 4. Improved vocal characteristics due to preservation of greater laryn¬ geal tissue bulk, an advantage that negates the main argument of propo¬ nents of radiation therapy for Tl lesions. Evaluation of the vocal quali¬ ty in 16 patients with laser-resected carcinomas showed that 13 (81% ) had excellent vocal results and that the quality of voice was good as long as the anterior commissure was not involved. These results are compara¬ ble with the quality of voices follow¬ ing radiation therapy as the modality of treatment.1415 For those cases where more bulk is removed so that a breathy voice results, a laryngoplasty procedure,1617 or later Teflon injection, promises further improvement and at worst, is no different from the voice

result with external

hemilaryngecto¬

my. 5. Retention of all other treatment options should the tumor recur or a second primary tumor develop later. 6. Results are as good as those from more aggressive forms of treatment in selected cases. Of the 23 group

patients described here who have been followed up for 18 months to five years, none have died of their laryn¬ geal disease or have required radia¬

tion therapy or an open surgical pro¬ cedure for cure. For all of the above reasons, we believe that laser endoscopie resection to include cordectomy or partial cor¬ dectomy represents an extension of the movement toward conservative laryngeal surgery, and should be con¬ sidered by all to be of use in the management of laryngeal carcinoma. A third major area in which we believe the laser has impact is for the treatment of carcinoma in situ or car¬ cinoma with microinvasion, which involves multiple areas within the lar¬ ynx, especially bilateral cord lesions. Multiple "skip" areas and varying degrees of involvement complicate not only treatment but also diagnosis.

Multiple cup forceps biopsy specimens

of these skip areas are usually bloody, which makes adequate sampling diffi¬ cult. It is also difficult to orient these small specimens in the pathology lab¬ oratory. Wide laser resection of the mucosal surfaces allows step section¬ ing, more precise pathologic examina¬ tion of the specimen, and a more complete tissue sampling than can be done otherwise. The treatment options in patients with carcinoma in situ, carcinoma with microinvasion with diffuse but superficial disease, or skip areas of involvement have been limited histor¬

ically to repeated endoscopie strip¬ ping, hemilaryngectomy, and radia¬ tion therapy, all of which have disad¬ vantages.18 Conservative external procedures seem inappropriate due to inordinate tissue loss and, hence, impaired function relative to the severity of the disease state. Radia¬ tion therapy requires a lengthy course

therapy with the inclusion of nor¬ mal tissue and secondary long-term changes, and it does not sterilize the of

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epithelium or prevent further dys¬ plastic progression. Surgical vocal cord stripping, the previously pre¬ ferred method of therapy for carcino¬ ma in situ, is difficult to control and is less than satisfactory when multiple skip areas are involved.

Norris and Peale" and Maran et al20 have shown that biopsy of microinva¬ sive lesions may result in total exci¬ sion and cure. Stutsman and McGavran21 support the concept of ultracon¬ servative management (ie, postbiopsy

observation alone) of superficially

invasive epidermoid carcinomas of the concept may be valid, as it is documented by their series of 60 patients with Tl lesions who underwent hemilaryngectomy; step sections of the specimens showed that 20% of the patients had no resid¬ ual tumor. Substitution of the microscopic-endoscopic-laser mucosal retrue vocal cord. This

section and vaporization technique for observation and later definitive treat¬ ment, for immediate irradiation, or for hemilaryngectomy ensures a more complete removal of abnormal tissue, and allows the physician greater con¬ fidence in his or her therapy while

simultaneously avoiding

overtreat-

ment, either from radiation therapy or

hemilaryngectomy.

We believe that endoscopie laser therapy of lesions diagnosed patho¬ logically as microinvasive carcinoma arising within carcinoma in situ is the preferable alternative to mere obser¬ vation or to the more aggressive options of radiation therapy or exter¬ nal hemilaryngectomy. For the pa¬ tient with multiple areas of mucosal involvement, more than one laser pro¬ cedure is often necessary. Obviously, discontinuance of smok¬ ing is mandatory for all patients with

laryngeal carcinoma, as are a good patient-physician relationship and close follow-up. The application of the laser to microscopically-controlled, transoral, endoscopie laryngeal surgery has

extended the field of conservation laryngeal cancer surgery. The tech¬ nique allows a more expeditious, lowcost alternative to radiation therapy and hemilaryngectomy, provides an equal cure rate, and allows greater tissue conservation with its attendant better functional voice results. The use of laser and venturi jet ventilation in the patient with obstructive laryngeal cancer can safe¬ ly establish a stable airway to allow time for an orderly preoperative eval¬ uation and preparation for definitive therapy, without the risk of the increased stornai recurrence that fol¬ lows tracheostomy.

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Surg Annu 1974;6:459-476. 3. Strong MS: Laser excision of carcinoma of the larynx. Laryngoscope 1975;85;1286-1289. 4. Annyas AA, Van Overbeek JJM, Escajadillo JR, et al: CO, laser in malignant lesions of the larynx. Laryngoscope 1984;94:836-838. 5. Lynch RC: Intrinsic carcinoma of the larynx, with a second report of the cases operated on by suspension and dissection. Trans Am Laryngol Assoc 1920;42:119-126. 6. New GB, Dorton HE: Suspension laryngoscopy in the treatment of malignant disease of the hypopharynx and larynx. Mayo Clin Proc 1941;

16:411-416. 7. Lillie JC, DeSanto LW: Transoral surgery of early cordal carcinoma. Trans Am Acad Ophthal-

mol

Otolaryngol 1973;77:92-96.

8. Vaughan CW, Strong MS, Shapshay SM: Treatment of T1 and in situ glottic carcinoma: The transoral approach. Otolaryngol Clin North

Am 1980;13:509-513. 9. Strong MS, Jako GJ: Laser surgery in the larynx: Early clinical experience with continuous CO2 laser. Ann Otol 1972;81:791-798. 10. Davis RK, Shapshay SM, Vaughan CW, et al: Pretreatment airway management in obstructing carcinoma of the larynx. Otolaryngol Head Neck Surg 11. Koufman JA, Little FB, Weeks DB: Proximal large-bore jet ventilation for laryngeal laser surgery. Arch Otolaryngol Head Neck Surg

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Laryngoscope 1982;92:980-984. 14. Koufman JA: The endoscopic management of early vocal cord carcinoma with the carbon dioxide laser: Clinical experience and a proposed subclassification. Otolaryngol Head Neck Surg

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