CO2 Transoral Microsurgery for Supraglottic Squamous Cell Carcinoma

Cinzia Mariani,Clara Gerosa,Natalia Chuchueva,Giovanni B Sambiagio,Elisa Lecis,Filippo Carta,Roberto Puxeddu

doi:10.3389/fonc.2018.00321

Abstract

The present study analyzed the results of the endoscopic approach to T1, T2 and selected T3 supraglottic carcinoma with the aim of reviewing functional and oncologic outcomes after different types of endoscopic supraglottic laryngectomies. This is a retrospective clinical study of 42 consecutive patients (mean age of 61.8 years, 33 males, 9 females) treated by the senior author for supraglottic squamous cell carcinoma with a transoral CO2 laser approach and reviewed from November 2010 to September 2017. Surgical procedures were classified according to the European Laryngological Society. In addition to the standardized transoral supraglottic laryngectomies, we introduced a modified type IVb by sparing the inferior third of the arytenoid if not directly involved in the tumor. Swallowing was evaluated with the Swallowing Performance Status Scale reported by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology. Survival probabilities were estimated using Kaplan-Meier curves. Two type I, 2 type IIa, 2 type IIb, 3 type IIIa, 12 type IIIb, 13 type IVa, 3 type modified IVb, and 5 type IVb supraglottic laryngectomies were performed. Twenty-one patients (50%) underwent primary neck dissection. The pathologic TNM classification according to the 8th edition of the American Joint Committee on Cancer system was as follows: 9 pT1cN0, 2 pT1N0, 1 pT1N1, 7 pT2cN0, 1 rypT2cN0, 9 pT2N0, 4 pT2N1, 2 ypT2N1, 2 pT3cN0, 2 rypT3cN0, 1 pT3N1, and 2 pT3N2b. Mean follow-up was 3.4 years (range of 9 months to 6 years). According to the Kaplan–Meier analysis, 5-year disease-specific survival, local-relapse-free survival, nodal-relapse-free survival, overall laryngeal preservation and overall survival of patients without previous head and neck radiotherapy/open surgery were 100%, 95.2%, 87.8%, 100%, and 64.6%, respectively. Patients who underwent type I, IIa, and IIb resections (n = 6) started oral feeding the day after surgery, patients who underwent type III-IVb modified resections (n = 31) started oral feeding 3–4 days after surgery, and patients who underwent standard type 4b resections (n = 5) started oral feeding 7 days after surgery. Three months after surgery, patients without a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed significantly better swallowing compared to patients who underwent standard type IVb resection: grade 4–6 impairment of swallowing in 8 and 66.7% of cases, respectively (p = 0.006072); patients with a clinical history of previous head and neck radiotherapy/open surgery who underwent type III, IVa, and modified IVb resections showed not statistically significant better swallowing compared to patients who underwent standard type IVb resection: grade 4–6 impairment of swallowing at 3 months in 16.7% and 50% of cases, respectively (p = 0.23568). Transoral CO2 laser supraglottic laryngectomy is an oncologic sound alternative to traditional open neck surgery and chemo-radiotherapy. Recovery of swallowing is significantly worsened after total resection of the arytenoid. Modified type IVb procedure leaving intact, when possible, the inferior third of the arytenoid and consequently the glottic competence, improves functional outcome.

Highlights

Squamous cell carcinoma (SCC) arising from the vestibule, the false cords, and the epiglottis with or without limited extension to the pyriform sinus and to the arytenoid may be treated through an endoscopic and organ-preservation approach that allows for the complete removal of the lesion without the need for “open surgery”.Currently, endoscopic CO2 laser supraglottic laryngectomy (ESL) targets mainly Tis, T1, and T2 tumors involving the epiglottis, the false vocal cords, and the aryepiglottic folds and selected cases of T3 and T4 supraglottic lesions (1–3).The choice of the most adequate treatment shouldn’t be based only on the oncologic results of a procedure, and quality of life issues have to be considered
Alcohol consumption was reported by 30 patients (71.4%), and daily tobacco consumption was reported by 32 patients (76.2%)
Alonso first described the supraglottic laryngectomy as a conservative treatment for supraglottic tumors through an external approach (12), but the first author who described transoral CO2 laser surgery for the removal of a supraglottic carcinoma was Vaughan in 1978 (13)

Summary

Introduction

Squamous cell carcinoma (SCC) arising from the vestibule, the false cords, and the epiglottis with or without limited extension to the pyriform sinus and to the arytenoid may be treated through an endoscopic and organ-preservation approach that allows for the complete removal of the lesion without the need for “open surgery”.Currently, endoscopic CO2 laser supraglottic laryngectomy (ESL) targets mainly Tis, T1, and T2 tumors involving the epiglottis, the false vocal cords, and the aryepiglottic folds and selected cases of T3 and T4 supraglottic lesions (1–3).The choice of the most adequate treatment shouldn’t be based only on the oncologic results of a procedure, and quality of life issues have to be considered. Endoscopic CO2 laser supraglottic laryngectomy (ESL) targets mainly Tis, T1, and T2 tumors involving the epiglottis, the false vocal cords, and the aryepiglottic folds and selected cases of T3 and T4 supraglottic lesions (1–3). Vocal function is generally not significantly impaired by supraglottic resection except during the wound healing period soon after the surgical procedure, while partial or complete resection of supraglottic structures can be burdened by post-operative aspiration during swallowing (4). The need for a nasogastric feeding tube, tracheostomy and/or a percutaneous endoscopic gastrostomy (PEG) are the main criteria used to evaluate early and long-term post-operative functional impairment (5, 6), but recovery of swallowing could be impaired by different degrees of aspiration, and feeding intake limitations can be observed even in patients without tracheostomy and/or PEG.

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Conclusion