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Unformatted text preview: Laser Excision of Laser Excision of Laryngeal Cancers Camysha Wright, MD Michael Underbrink, MD University of Texas Medical Branch Department of Otolaryngology November 28, 2007 Background Background Conservation laryngeal surgery refers to: Any procedure that maintains physiologic speech and swallow function without the need for a permanent tracheostoma. Goal in conservation laryngeal surgery Preserve maximum laryngeal function without compromising the cure rate. Complete removal of all malignant disease which should be achieved while preserving the 4 basic functions of the larynx deglutition, respiration, phonation, and airway protection. Background Background Transoral laser microsurgery maintains all options for further treatment. During the approach it can be converted to external approach at any time Postoperatively laser surgery can be reapplied Background Background Lymphatic drainage of the larynx I Sparse anteriorly and at the level of the glottis. Richer in the supraglottic and subglottic regions, as well as the posterior ½ of the larynx. Three fibroelastic membranes serve as the major barriers to the spread of cancer from (and to) the glottic region the conus elasticus inferiorly, the quadrangular membrane laterally, and the thyrohyoid membrane superiorly. Broyles’ Tendon is the insertion of the vocalis tendon into the thyroid cartilage in the area of the anterior commissure. Anatomy: Laryngeal Cartilage Anatomy: Laryngeal Cartilage Anatomy: Laryngeal Muscles Anatomy: Laryngeal Muscles Anatomy Anatomy Pathophysiology of Laryngeal Pathophysiology of Laryngeal Cancer Limitation of true vocal cord mobility correlates with a worsening prognosis, Early glottic cancer infrequently metastasizes, and when it does, it is almost always to the ipsilateral neck. Lesions limited to the true vocal cords (e.g., T1 and T2) demonstrate a 5% incidence of cervical metastasis This figure jumps to 30­40% for T3 lesions. Pathophysiology of Laryngeal Pathophysiology of Laryngeal Cancer Supraglottic squamous cell carcinoma is a different disease process from its glottic counterpart. Supraglottic carcinoma exhibits a much higher incidence of occult nodal metastasis and frank nodal metastasis at presentation. 19% of survivors will develop a second respiratory tract primary within 5 years. Staging­ Primary Tumor (T) Staging­ Primary Tumor (T) TX Minimum requirements to assess primary tumor cannot be met T0 No evidence of primary tumor Tis Carcinoma in situ Staging­ Supraglottis Staging­ Supraglottis T1 T2 Tumor limited to one subsite of supraglottis with normal vocal cord mobility Tumor involves mucosa of more than one adjacent subsite of supraglottis or glottis, or region outside the supraglottis (e.g. mucosa of base of the tongue, vallecula, medial wall of piriform sinus) without fixation T3 Tumor limited to larynx with vocal cord fixation and or invades any of the following: postcricoid area, preepiglottic tissue, paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) T4a Tumor invades through the thyroid cartilage and/or invades tissue beyond the larynx (e.g. trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Staging­ Glottis Staging­ Glottis T1 Tumor limited to the vocal cord (s) (may involve anterior or posterior commissure) with normal mobilty T1a Tumor limited to one vocal cord T1b Tumor involves both vocal cords T2 Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility T3 Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) T4a Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Staging­ Nodes Staging­ Nodes N0 No cervical lymph nodes positive N1 Single ipsilateral lymph node ≤ 3cm N2a Single ipsilateral node > 3cm and ≤6cm N2b Multiple ipsilateral lymph nodes, each ≤ 6cm Bilateral or contralateral lymph nodes, each ≤6cm Single or multiple lymph nodes > 6cm N2c N3 Staging­ Metastasis Staging­ Metastasis M0 No distant metastases M1 Distant metastases present Evaluating for conservation surgery Evaluating for conservation surgery Principles Must be able to confidently predict the extent of tumor Cricoarytenoid unit, and not the true vocal cord (TVC), is the basic functional unit of the larynx that makes conservation laryngeal surgery possible. Resection of normal tissue in organ preservation surgery is necessary to achieve consistent functional outcomes. It is impossible to know the extent of submucosal tumor involvement preoperatively. Workup Workup Preoperatively, all patients should undergo a thorough head and neck physical examination, including mirror exam or flexible laryngoscopy and videostroboscopy. It is vitally important to assess for the presence or absence of a mucosal wav e Implies the absence or presence of involvement of the vocalis muscle. Workup Workup Videostroboscopy Advantages: allows apparent “slow motion” assessment of mucosal vibratory dynamics, video documentation Disadvantages: time consuming, expensive Laser— Laser— basics Light Amplification by Stimulated Emission of Radiation Coherent Collimated photons in phase temporally/spatially tight beam, parallel paths Monochromatic one wavelength Lasers Lasers All laser devices have an optical resonating chamber (cavity) with two mirrors. The space between these mirrors is filled with an active medium, such as Ar, Nd:YAG, or CO2. An external energy source (e.g., an electric current) excites the active medium within the optical cavity. Lasers Lasers Spontaneous emission is taking place in all directions. Light (photons) emitted in the direction of the long axis of the laser is retained within the optical cavity by multiple reflections off of the precisely aligned mirrors. One mirror is completely reflective, and the other is partially transmissive. Stimulated emission occurs when a photon interacts with an excited atom in the optical cavity. This yields pairs of identical photons that are of equal wavelength, frequency, and energy and are in phase with each other. This process occurs at an increasing rate with each passage of the photons through the active medium Monochromatic Coherent Collimated Background Background Maiman built the first laser in 1960. With synthetic ruby crystals, this laser produced electromagnetic radiation at a wavelength of 0.69 µm in the visible range of the spectrum. Although the laser energy produced by Maiman's ruby laser lasted less than 1 ms, it paved the way for explosive development and widespread application of this technology Background Background Two important advances allowed the laser to be useful in otolaryngology: (1) 1965, the carbon dioxide (co2) laser was developed (2) 1968, Polanyi developed the articulated arm to deliver the infrared radiation from the co2 laser to remote targets. Simpson and Polanyi described the series of experiments and new instrumentation that made this work possible. Background Background Strong and Jako in 1972 introduced CO2 laser excision for the treatment of laryngeal disease. The advantages they noted were precise control, minimal bleeding, and the absence of post­operative edema. Steiner further developed the technique of TLM with a study in Gottenberg, Germany Laser­­basics Laser­­basics Light can be: Reflected (bounces off) Scattered (random dispersal) Transmitted (passes through unchanged) Refracted (change in direction) Absorbed (maximal clinical benefit) Reflection Reflection Scattering Scattering Transmission Transmission Absorption Absorption Laser injury Laser injury The wound created by the carbon dioxide laser, showing the representative zones of injury. Laser – emission modes Laser – emission modes Continuous Pulsed/Superpulsed (microsec) Uninterrupted beam Relatively constant power Higher energy/shorter duration pulses Q­switched (nanosec) Extremely high energy/short pulse duration Lasers Lasers With most surgical lasers, the physician can control three variables: (1) power (measured in watts); (2) spot size (measured in millimeters); and (3) exposure time (measured in seconds). Power Power Power is the least useful variable May be kept constant with widely varying effects, depending on the spot size and duration of exposure Irradiance more useful measure of the intensity of the beam at the focal spot it considers the surface area of the focal spot. Spot Size Spot Size Power and spot size are considered together, and a combination is selected to produce the appropriate irradiance. Exposure Time Exposure Time The surgeon can vary the amount of energy delivered to the target tissue by varying the exposure time. Fluence refers to the amount of time (measured in seconds) that a laser beam irradiates a unit area of tissue at a constant irradiance. Laser – tissue interaction Laser – tissue interaction Each tissue differs in absorption characteristics and relaxation time (time necessary to release 50% of energy) Penetration is influenced by target chromophore (more absorption = less penetration) Laser spectrum Laser spectrum Laser spectrum Laser spectrum Laser Wavelength (nm) Er:YAG 294 Argon 488/514 KTP:YAG 532 Copper vapor 578 FLPPD 585 Long pulse 595­600 Ruby, Q­switched 694 Long pulse 694 Q­switched Alexandrite 755 Nd:YAG 1064 Q­switched YAG 1064 CO2 10600 Application Skin resurfacing Vascular lesions Vascular lesions Vascular lesions Vascular lesions Leg veins Tattoo removal Hair removal Tattoo removal Deep vascular Tattoo removal Cut/coag/resurf CO2 Laser CO2 Laser Microspot CO2 Laser CO2 laser energy is absorbed by water allowing Reinke’s space to act as a natural barrier to protect the vocal ligament Provides excellent hemostasis Thermal trauma can be detrimental Gallo, et al. Laryngoscope. Gallo, et al. Laryngoscope. Volume 112(2), February 2002, pp 370­374 (B) Retrospective study 151 patients treated from April 1982 to June 1996 defined when laser resection of early­stage glottic carcinoma is indicated and compared the results obtained by laser surgery with other therapeutic options. Glottic tumors treated with type III, type IV, and type Va cordectomies according to the classification of endoscopic cordectomies proposed by the European Laryngological Society in 2000. Gallo, et al. Laryngoscope. Gallo, et al. Laryngoscope. Volume 112(2), February 2002, pp 370­374 (B) Table 1. Endoscopic Cordectomy: Classification by European Laryngological Society. Gallo, et al. Laryngoscope. Gallo, et al. Laryngoscope. Volume 112(2), February 2002, pp 370­374 (B) Table 2. Indication by Stage for Laser Resection Gallo, et al. Laryngoscope. Gallo, et al. Laryngoscope. Volume 112(2), February 2002, pp 370­374 (B) Cordectomies performed using a CO2 laser mounted on a Zeiss surgical microscope. Performed under general anesthesia. En­bloc excised tissue was completely detached the specimen was whole­mounted on a slide and oriented to mark the anterior and the medial margins. An accompanying legend was drawn adjacent to the lesion If the histologic examination revealed a positive margin, on frozen sections, the resection was extended until healthy margins were obtained. Gallo, et al. Laryngoscope. Gallo, et al. Laryngoscope. Volume 112(2), February 2002, pp 370­374. (B) They recommended that the transmuscular cordectomy (type III) is indicated in cases of small superficial tumors of the mobile vocal fold (T1a); the total cordectomy (type IV) is indicated in cases of T1a cancer with extension to the anterior commissure, and/or when the tumor involves the vocal fold in an infiltrative pattern and/or when the tumor size is more than 0.7 mm; the extended cordectomy encompassing the contralateral vocal fold (type Va) is indicated in cases of T1b cancer involving the anterior commissure or in horseshoe lesions Gallo, et al. Laryngoscope. Gallo, et al. Laryngoscope. Volume 112(2), February 2002, pp 370­374. (B) They found that all patients with carcinoma in situ Tis are free of disease with local control rate at 3 years of 100%; Of the 117 patients with stage T1a cancer 110 are free of disease at 3 years with local control rate of 94%; 4 patients died of other causes without evidence of local recurrence with an overall survival rate of 96.5%. Of the 22 patients with stage T1b cancer 20 are free of disease at 3 years with a local control rate of 91%; 2 died of other causes without evidence of local recurrence with an overall survival rate at 3 years of 83.2%. 1 patient died of other causes without evidence of local recurrence with an overall survival rate at 3 years of 95.4%. They concluded that endoscopic laser surgery is an efficacious and cost­effective treatment for early stage glottic cancer. Moreau: Laryngoscope, Volume 110(6).June Moreau: Laryngoscope, Volume 110(6).June 2000.1000­1006 (B) Retrospective study of 160 patients treated from 1988 to 1996 determine if laser endoscopic microsurgery is a reliable and appropriate approach in the treatment of laryngeal cancers. Glottic tumors were treated with either type I, type II, or type III cordectomy For supraglottic cancers, excision limited to a part of the vestibule, a trans­preepiglottic resection, or a radical supraglottic resection Moreau: Laryngoscope, Volume 110(6).June 2000.1000­1006 (B) Moreau: Laryngoscope, Volume 110(6).June 2000.1000­ 1006 (B) Moreau: Laryngoscope, Volume 110(6).June 2000.1000­ Moreau: Laryngoscope, Volume 110(6).June 2000.1000­ 1006 (B) A type I cordectomy, which passes through Reinke’s space, is used for carcinoma in situ (Fig. 1A). If the lesion is bilateral, a one­ sided type I cordectomy is carried out up to the midline at the anterior commissure, at the first operation. This is completed on the other side 2 months later, with removal of the anterior portion of the previous resection. The two excisions thus overlap slightly at the anterior commissure (Fig. 1B). Moreau: Laryngoscope, Volume 110(6).June 2000.1000­ Moreau: Laryngoscope, Volume 110(6).June 2000.1000­ 1006 (B) Depending on the thickness of the resected glottic musculature, the type II cordectomy is subdivided into three subgroups, types IIa, IIb, and IIc (Fig. 1C). When the tumor does not involve the inferior part of the cord, an inferior muscular band can be preserved over the whole length ( Fig. 1D). It is mandatory to use palpation to assess the mobility of the tumor at the anterior commissure with respect to the thyroid cartilage ( Fig. 1E). Moreau: Laryngoscope, Volume 110(6).June 2000.1000­ Moreau: Laryngoscope, Volume 110(6).June 2000.1000­ 1006 (B) The trans­preepiglottic vestibulectomy for tumors of the laryngeal surface of the epiglottis with no radiological involvement of the preepiglottic space (Fig. 2B). Radical vestibulectomies if this space was partially occupied with tumor (Fig. 2C). Limited supraglottic involvement, resection limited to the involved zone (Fig. 2A). Moreau: Laryngoscope, Volume 110(6).June 2000.1000­ Moreau: Laryngoscope, Volume 110(6).June 2000.1000­ 1006 (B) A neck dissection is carried out for supraglottic tumors, except for microinvasive infrahyoid cancers (with <2 mm of infiltration). A bilateral dissection is carried out for midline tumors. 5/19 patients with supraglottic tumors had bilateral neck dissections, 9 had unilateral dissections, and 5 were not dissected Postoperative radiotherapy was carried out in nine patients. Two had glottic tumors One patient had a subglottic tumor involvement of the inferior edge of the resection. Six patients had supraglottic tumors, with histologically demonstrated nodal involvement in five and a multifocal tumor in the sixth. Moreau: Laryngoscope, Volume 110(6).June 2000.1000­ Moreau: Laryngoscope, Volume 110(6).June 2000.1000­ 1006 (B) Survival at 5 years No local recurrences were noted, in either group 97% for the 98 infiltrative glottic tumors 100% for the 18 infiltrative supraglottic and 27 in situ carcinomas. One patient died of his cancer, with lung metastases after neck recurrence. Concluded series demonstrated oncologic validity of this surgical approach Jackel et al. Eur Arch Otolaryngol Jackel et al. Eur Arch Otolaryngol (2007) 264: 577­585. (D) Report of an international symposium of 25 years with TLM Noted that Steiner has promoted selective neck dissection for the treatment of N0–N2 necks since the early 1980s The Göttingen experience oncological results achieved with routine selective neck dissection are similar to those reported after (modified) radical neck dissection Jackel et al. Eur Arch Otolaryngol Jackel et al. Eur Arch Otolaryngol (2007) 264: 577­585. (D) Noted that the role of radiotherapy is based on intraoperative and histopathologic findings. Referred to Göttingen concept of function preserving therapy for the advanced neck pN2/3, extracapsular spread, infiltration of lymph vessels or incomplete removal of primary tumor Laser Safety – Eye protection Laser Safety – Eye protection Patients undergoing CO2 laser surgery should have a double layer of saline­moistened eye pads placed over the eyes All operating room personnel should wear protective eyeglasses with side protectors. Regular eyeglasses or contact lenses protect only the areas covered by the lens do not provide protection from possible entry of the laser beam from the side. Surgeon need not wear protective glasses. The optics of the microscope provide the necessary protection Laser Safety – Eye protection Laser Safety – Eye protection Patient undergoing carbon dioxide laser microlaryngoscopy with jet ventilation. A, Saline­moistened eye pads are secured with silk tape. The eyes are first taped closed with silk tape to prevent corneal abrasions from the eye pads. B, Saline­moistened towels are placed around the patient's head to cover all skin surfaces. Laser Safety – Eye protection Laser Safety – Eye protection Laser Safety Laser Safety Skin Protection When microlaryngeal laser surgery is being performed, Beam might partially reflect off the proximal rim of the laryngoscope rather than go down it. Saline­saturated surgical towels completely drape the patient's face. Only the proximal lumen of the laryngoscope is exposed. Teeth in the operative field also need to be protected. Saline­saturated Telfa, surgical sponges, or specially constructed metal dental impression trays can be used. Laser Safety Laser Safety Aside from a few minor eye injuries from a laser beam exposure, most serious accidental injuries related to laser use can be traced to the ignition of surgical drapes and airway tubes Laser Safety Laser Safety Methylene blue­colored saline should be used to inflate the cuff. Saline­saturated cottonoids are then placed above the cuff in the subglottic larynx to further protect the cuff. If the cuff deflates cottonoids turn blue to warn the surgeon of impending danger. The tube should then be removed and replaced with a new one. Complications Complications One of the most devastating complications is endotracheal tube ignition and resulting injury to the laryngotracheal mucosa. A nonflammable, universally accepted endotracheal tube for all types of laser surgery of the upper aerodigestive tract does not exist. The traditional polyvinyl endotracheal tube should not be used, either wrapped or unwrapped. It offers the least resistance to penetration by the laser beam and tissue destruction associated with combustion of this tube is the most severe. Endotracheal tubes for laser surgery that are wavelength specific are now available from several manufacturers and should be used at all times unless jet ventilation techniques are used. Complications Complications Granuloma formation at the anterior commissure was a common occurrence in the study by Moreau. These granulomas tended to last for several months before spontaneous resolution. Other complications, which were few, included: laryngeal hemorrhage, pneumothorax, aspiration pneumonia, subcutaneous air, and p relaryngeal abscess. Anterior webs can result from anterior commissure resection; these were treated with repeat endoscopic procedures. Conclusions Conclusions Microendoscopic laser surgery Advantages of laser resection include provides an excellent alternative to radiotherapy in the treatment of early­stage glottic cancer. minimal bleeding, precise control of resection, and the absence of postoperative edema. Cure rates of patients with early­stage glottic carcinoma treated with CO2 laser are equal to those achieved with radiation therapy. Nevertheless, the role and the indications of this technique in the treatment of early­stage glottic cancer has not been defined accurately and remains controversial. References References Eckel EH, Thumfart W, Jungehulsing M, Sittel C, Stennert E. Transoral laser surgery for early glottic carcinoma. Eur Arch Otolaryngol 2000; 257: 221–226. Gallo A, Mocetti P, De Vincentiis M, et al. Neoplastic infiltration of laryngeal cartilages: histocytochemical study. Laryngoscope 1992; 102: 891–895. Gallo A, et al. CO2 Laser Cordectomy for Early­Stage Glottic Carcinoma: A Long­ Term Follow­up of 156 Cases. Laryngoscope. Volume 112(2), February 2002, pp 370­374. Hirano M, Hirade Y, Kawasaki H. Vocal function following carbone dioxide laser surgery for glottic carcinoma. Ann Otol Rhinol Laryngol 1985; 94: 232–235. Jones AS, et al. Treatment of early laryngeal cancers (T1­T2 N0): surgery or irradiation. Head and Neck. Vol 26, Issue 2, pages 127­135. Moreau PR. Treatment of laryngeal carcinomas by laser endoscopic microsurgery. Laryngoscope 2000; 110: 1000–1006 Myers EN, Wagner RL, Johnson JT. Microlaryngoscopic surgery for T1 glottic lesions: a cost­effective option. Ann Otol Rhinol Laryngol 1994; 103: 28–30. Rebeiz EE, Wang Z, Annino DJ, et al. Preliminary clinical results of window partial laryngectomy: a combined endoscopic and open technique. Ann Otol Rhinol Laryngol 2000; 109: 123–127. Rydell R, Schalen L, Fex S, Elner A. Voice evaluation before and after laser excision vs radiotherapy of T1a glottic carcinoma. Acta Otolaryngol 1995; 115: 560–565. Shapshay SM, Wang Z, Rebeiz EE, et al. ‘Window’ laryngoplasty: a new combined laser endoscopic and open technique for conservation surgery. References References Bailey BJ. Vertical Partial Laryngectomy. Atlas of Head & Neck Surgery – Otolaryngology . 2nd Edition. Lippincott, Williams & Wilkins. 2001. Pages 184­187. Bailey BJ. Early Glottic Carcinoma. Head & Neck Surgery – Otolaryngology. 2nd Edition. Lipincott­Raven. 1998. Pages 1703­1724. Damm M, Sittel C, et al. Transoral CO2 Laser for Surgical Management of Glottic Carcinoma in Situ. Laryngoscope. Volume 110. Number 7. July 2000. Pages 1215­1221. Davis RK. Endoscopic Surgical Management of Glottic Laryngeal Cancer. Otolaryngologic Clinics of North America. Volume 30. Number 1. February 1997. Pages 79­86. Desanto LW. Supraglottic Laryngectomy. Head & Neck Surgery – Otolaryngology. 2nd Edition. Lipincott­Raven. 1998. Pages 1725­1738. Flint PW. Minimally Invasive Techniques for Management of Early Glottic Cancer. Otolaryngologic Clinics of North America. Volume 35. 2002. Pages 1055­1066. Gallo A, de Vincentiis M. CO2 Laser Cordectomy for Early­Stage Glottic Carcinoma: A Long­Term Follow­up of 156 Cases. Laryngoscope. Volume 112. Number 2. February 2002. Pages 370­374. Johnson JT, Curtin H. Carcinoma of the Supraglottic Larynx. SIPAC. Second Edition. American Academy of Otolaryngology – Head and Neck Surgery Foundation, Inc. 2000. Moreau PR. Treatment of Laryngeal Carcinomas by Laser Endoscopic Microsurgery. Laryngoscope. Volume 110. Number 6. June 2000. Pages 1000­1006. Osguthorpe JD, Putney FJ. Open Surgical Management of Early Glottic Carcinoma. Otolaryngologic Clinics of North America. Volume 30. Number 1. February 1997. Pages 87­99. Simpson CB, Postma GN, et al. Speech Outcomes After Laryngeal Cancer Management. Otolaryngologic Clinics of North America. Volume 30. Number 1. February 1997. Pages 189­205. Tufano RP. Organ Preservation Surgery for Laryngeal Cancer. Otolaryngologic Clinics of North America. Volume 35. 2002. Pages 1067­1080. Zeitels SM. Surgical Management of Early Supraglottic Cancer. Otolaryngologic Clinics of North America. Volume 30. Number 1. February 1997. Pages 59­78. Zeitels SM, Shapshay SM. Endoscopic Management of Glottic Cancer. SIPAC. First Edition. American Academy of Otolaryngology – Head and Neck Surgery Foundation, Inc. 2002. ...
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