Transoral CO2 Laser Surgery Research Articles

VoiceS: voice quality after transoral CO2 laser surgery versus single vocal cord irradiation for unilateral stage 0 and I glottic larynx cancer—a randomized phase III trial

BackgroundSurgery and radiotherapy are well-established standards of care for unilateral stage 0 and I early-stage glottic cancer (ESGC). Based on comparative studies and meta-analyses, functional and oncological outcomes after both treatment modalities are similar. Historically, radiotherapy (RT) has been performed by irradiation of the whole larynx. However, only the involved vocal cord is being treated with recently introduced hypofractionated concepts that result in 8 to 10-fold smaller target volumes. Retrospective data argues for an improvement in voice quality with non-inferior local control. Based on these findings, single vocal cord irradiation (SVCI) has been implemented as a routine approach in some institutions for ESGC in recent years. However, prospective data directly comparing SVCI with surgery is lacking. The aim of VoiceS is to fill this gap.MethodsIn this prospective randomized multi-center open-label phase III study with a superiority design, 34 patients with histopathologically confirmed, untreated, unilateral stage 0-I ESGC (unilateral cTis or cT1a) will be randomized to SVCI or transoral CO2-laser microsurgical cordectomy (TLM). Average difference in voice quality, measured by using the voice handicap index (VHI) will be modeled over four time points (6, 12, 18, and 24 months). Primary endpoint of this study will be the patient-reported subjective voice quality between 6 to 24 months after randomization. Secondary endpoints will include perceptual impression of the voice via roughness – breathiness – hoarseness (RBH) assessment at the above-mentioned time points. Additionally, quantitative characteristics of voice, loco-regional tumor control at 2 and 5 years, and treatment toxicity at 2 and 5 years based on CTCAE v.5.0 will be reported.DiscussionTo our knowledge, VoiceS is the first randomized phase III trial comparing SVCI with TLM. Results of this study may lead to improved decision-making in the treatment of ESGC.Trial registrationClinicalTrials.gov NCT04057209. Registered on 15 August 2019. Cantonal Ethics Committee KEK-BE 2019-01506

Solitary fibrous tumor of the larynx treated with transoral endoscopic CO2 laser surgery – a case report and literature review

Presented is a case of an exceptionally rare laryngeal tumor removed by means of endoscopic surgery using a CO2 laser following earlier embolization of the left superior laryngeal artery. From the patient’s perspective, it is extremely important that the procedure be performed in a possibly least invasive manner so that no laryngeal or pharyngeal dysfunctions develop as the consequence thereof. </br> </br> Due to the total nature of the resection with negative (R0) resection margins being achieved, and due to the histopathological examina-tion being suggestive of the benign nature of the lesion, no adjuvant treatment was required in the reported case. </br> </br> Due to the sporadic incidence of SFTs within the laryngeal region and the incompletely studied biology of these tumors, long-term follow-up in the setting of an outpatient laryngological clinic is advisable.

Flexible endoscopic laser surgery for early glottic carcinoma

ObjectiveFlexible endoscopic laser surgery (FELS) is able to overcome some limitations of traditional transoral CO2 laser surgery. The objective of this study was to assess the efficacy of FELS in the treatment of T1-T2 glottic carcinoma. MethodsWe applied FELS for 120 patients with T1-T2 glottic carcinoma. Tumour ablation was performed with Nd:YAG laser. In 76 (63.3%) cases the intervention was performed under local anesthesia. Twenty nine (24.2%) patients (T1b - 2, T2–27) underwent postoperative radiation therapy (RT). ResultsSuccessful treatment, with local control and larynx preservation, was obtained in 106 cases (88.3%), with mean follow-up of 6.4 years. More than 50% of the patients were followed-up over 5 years. ConclusionsFELS can be proposed as an alternative treatment method for patients with early glottic carcinoma. The advantages of the method include: possibility of applying treatment under local anesthesia, that allows avoiding of general anesthesia and its related risks; applicability to patients with contraindications to general anesthesia and patients with anatomic particularities, that make transoral microsurgery impossible, allowing avoidance of the laryngofissure and tracheotomy.

Low Grade Laryngeal Chondrosarcoma: Clinical Presentation, Management and Short Term Outcome.

Low grade laryngeal chondrosarcomas are rare, slow growing tumors. Surgical removal of the tumor along with preservation of laryngeal function is the preferred modality of treatment. We report a case of a large low grade chondrosarcoma removed by transoral CO2 LASER surgery which had avoided an open surgery.

Transoral CO2 laser surgery for early glottic carcinoma with anterior commissure involvement

To explore the feasibility and effect of CO2 laser surgery for early glottic carcinoma with anterior commissure involvement. Twenty-seven patients with T1b glottic squamous cell carcinoma who underwent transoral CO2 laser surgery as the primary modality of treatment from January 2008 to August 2013 were reviewed. All patients were males and the age ranged from 46 to 81 years old. The patients did not receive any other treatments. Preoperative enhanced CT scan was performed to assess the status of the tumors and the lamina of thyroid cartilage. All the patients without the lamina of thyroid cartilage involved underwent transoral CO2 laser surgery. Among 27 cases, aside from 1 patient converted to open operation due to inadequate exposure, 26 patients were successfully implemented operation. All the patients were followed-up for 12 to 60 months (median 26 months) and no recurrence. Granulation occurred four to six weeks after operation in all patients. Among them, granulation disappeared automatically three to six months in 22 patients and was resected with local anesthesia in other 4 patients, which the pathological results were inflammatory lesion. All patients did not undergo tracheotomy and nasogastric feeding, with an average stay of three days in hospital after surgery, and had different degree of vocal cord adhesion 6 months later. Transoral CO2 laser surgery is an ideal procedure for early glottic carcinoma with anterior commissure involvement. Better preoperative evaluation, endoscopic technique and satisfied exposure are keys to the success of operation.

Management of iatrogenic bilateral vocal cord paralysis by endoscopic transoral CO2 laser surgery – Report of two cases

Bilateral vocal fold paralysis is a rare condition. The commonest cause identified is mostly iatrogenic. It can be extremely debilitating for the patient who usually suffers from severe breathlessness on slightest exertion. Many of them requires a tracheostomy to maintain airway. The treatment of bilateral vocal cord palsy is a balance between phonation, airway and swallowing. Several surgical modalities have been described for cases which doesn't improve with conservative management. However transoral CO2 laser endoscopic arytenoidectomy has become the standard of management today for this condition. CO2 laser is arguably the most appropriate tool for cordectomy with the advantage of increased precision, better hemostasis and minimal tissue handling. We describe the procedure of posterior cordectomy with partial arytenoidectomy using transoral CO2 laser in two patients who were successfully managed for this condition in our centre.

Transoral CO2 laser epiglottectomy for early epiglottic carcinomas

To compare the functional results of transoral CO2 laser epiglottectomy with transcervical supraglottic laryngectomy and to find the landmarks for CO2 laser surgery. Forty-nine preoperatively untreated patients diagnosed as clinical T1-2N0M0 epiglottic carcinomas enrolled from June 1, 2006, to November 1, 2009 in the Second Affiliated Hospital of Harbin Medical University were studied retrospectively. Seventeen cases were treated by CO2 laser whereas 32 by open surgeries. The upper edge of thyroid cartilage and mucosal recess infra epiglottic tubercle could be used as intraoperation landmarks for transoral CO2 laser surgery. Optional neck dissections (II, III) were performed for 34 patients with tumors on laryngeal face, but not for 15 with tumors on the edges of epiglottis or small laryngeal face tumors. The follow-up for this study covers a period ranging from 3 to 6 years postoperatively. Four local recurrences were found for this study, 2 for laser surgery who underwent additional repeated exisions and 2 for conventional techniques, one received radiotherapy (60 Gy) and another with total laryngectomy. The incidence of lymph node metastasis was 10.2% (5/49) in all cases. Time of naso-feeding or hospitalisation was significantly shorter for CO2 laser treated patients than that for open techniques. Overall 3 year's survival rates were 100% and 90.6% for CO2 laser and the open techniques respectively. Compared to the open technique, transoral CO2 laser epiglottectomy is a well-tolerated and promising resection technique with low morbidity for early epiglottic carcinomas, and the identification of landmarks is useful for entire resection of epiglottis.

Transoral CO2 Laser‐Resection of Early Laryngeal Cancer

Objective: Authors report their experience (1987-2010) with transoral CO2 laser surgery of early glottic and supraglottic cancer. A total of 375 laser cordectomies were performed in 324 patients with Tis-T2 vocal cord tumors, and 63 patients with T1, T2 supraglottic tumour underwent transoral supraglottic laser resection. Method: Laser cordectomy of Tis (21), T1a (179), T1b (57), and T2-3 (32) tumors and supraglottic laser resection of 40 epiglottis (36 T1, 4 T1N1), 4 vestibular fold (T1), 13 vallecula (10 T2, 3 T2N1), and 6 aryepiglottic fold (3 T2, 3 T2N1) tumors with 10 ND was evaluated. Results: There was no recurrence after a single laser cordectomy in 87.5% of the patients (253/289 patients). Laser-specific survival is 92.7% (268/289). Five-year survival is 92.2% (214/232). “Local recurrence” was found in 36 of 289 patients (12.5%). In the supraglottic group, 47 patients are free of tumor after primary laser excision so far. Sixteen patients with local recurrence underwent salvage treatments. Late neck metastasis required 5 radical neck dissections (RND). Tumor-free survival is 75%. Survival after salvage therapy is 98%. The voice improved during the healing. Conclusion: Transoral CO2 laser surgery of the early vocal cord and supraglottic cancer proved to be a primary treatment option with success: good oncological and acceptable functional results.

The evolving management of laryngeal neuroendocrine carcinomas

Laryngeal neuroendocrine neoplasms are divided into two broad categories based on their tissue of origin: epithelial and neural [1]. Laryngeal epithelial neuroendocrine neoplasms are all malignant lesions (carcinomas) and are a subset of neoplasms that share specific morphologic, histochemical, immunohistochemical, ultrastructural and molecular characteristics. The major categories of laryngeal neuroendocrine carcinomas are typical carcinoid (well differentiated neuroendocrine carcinoma), atypical carcinoid (moderately differentiated neuroendocrine carcinoma), small cell neuroendocrine carcinoma (poorly differentiated neuroendocrine carcinoma) and large cell neuroendocrine carcinoma (poorly differentiated neuroendocrine carcinoma) [2]. The neural category consists only of paraganglioma which is invariably benign [3]. Although neuroendocrine neoplasms are uncommon in the larynx, they represent the most common non-squamous neoplasms arising in this area and to date more than 700 cases of them have been reported in the literature [1]. The atypical carcinoid is the most frequent laryngeal neuroendocrine carcinoma, followed by small cell neuroendocrine carcinoma, carcinoid tumor, and large cell neuroendocrine carcinoma. However, in the past large cell neuroendocrine carcinoma was classified under the umbrella term of atypical carcinoid so it may actually be more common than previously realized [4]. Accurate classification of the laryngeal epithelial neuroendocrine carcinomas requires knowledge of specific pathologic criteria separating the major categories. Neuroendocrine carcinomas of the larynx have widely varying prognosis, clinical management, and response to therapy. Thus, accurate classification is essential. Immunohistochemistry is an important diagnostic adjunct in the evaluation of these tumors, as it allows for definitive demonstration of neuroendocrine differentiation. For typical carcinoid, conservation surgery, particularly supraglottic laryngectomy, may be suitable because the supraglottis is the most frequent site of involvement. Transoral CO2 laser surgery can be a good alternative for appropriate cases because of the functional results and lower morbidity [5]. Elective neck dissection is not warranted. Bilateral selective neck dissection (levels II and III) is only indicated for clinically or pathologically proven cervical metastases [6]. The mainstay of treatment for atypical carcinoid of the larynx is surgical resection. As most tumors are located in the supraglottis, supraglottic laryngectomy is often the procedure of choice. Transoral CO2 laser surgery has been also employed to resect these tumors with oncologically sound results and with low morbidity [7]. Elective neck dissection appears to be warranted in view of the high incidence of both early cervical metastasis and subsequent involvement of cervical lymph nodes. Bilateral dissection of sublevel IIA and level III is only adequate for elective surgical treatment of the neck in supraglottic tumors [8]. Bilateral selective neck dissection (levels II and III) should be used therapeutically for metastatic disease. Post-operative radiotherapy is indicated in the presence of cervical lymph node metastases. Painful skin metastases from an This paper was written by members of the International Head and Neck Scientific Group (www.IHNSG.com).

Role of transoral CO2 laser surgery for severe pediatric laryngomalacia

Controversy exists as to the preferred treatment modality for managing refractory pediatric laryngomalacia (LM). Simultaneous bilateral procedures have been associated with supraglottic stenosis. Unilateral operations have a higher rate of secondary intervention. This prospective study was conceptualized to ascertain a preferred approach. A secondary goal was to correlate the surgical outcome with presenting symptoms and signs. Twenty-two children with severe LM met the criteria for enrollment. Bilateral CO(2) laser-assisted supraglottic laryngoplasties were performed in all cases. The procedure mainly consisted of division of the aryepiglottic fold. Nineteen (86%) patients met our defined success criteria. There were no surgical complications. Bilateral supraglottic laryngoplasty has a role in the management of severe refractory LM.

Evaluation of CO2 Laser Surgery for Early Carcinoma Larynx

ABSTRACTObjectiveTo evaluate the effectiveness of transoral endoscopic laser surgery in the treatment of early laryngeal cancers in comparison to external radiotherapy.Method: The patients included in the study were those who reported to the ENT department of a tertiary care hospital with early malignant lesions of the larynx.ResultOur study revealed a local recurrence rate of 15% in the radiotherapy arm but only 10% in the CO2laser arm; however, this difference was not statistically significant. The only parameter in the analysis of voice which showed a statistically significant difference between the two arms was roughness which was better in the radiotherapy arm at 6 months. The major complication following transoral CO2laser surgery was persistent hoarseness which was seen in six patients and it resolved completely on continuation of conservative measures. Severe laryngeal edema following treatment was seen in two patients. Statistically significant difference was noted in patient acceptability in favor of CO2laser.ConclusionEndoscopic CO2laser surgery in early laryngeal cancer leads to similar control of the disease as with the traditional methods, with better patient acceptability, low morbidity and good functional results.

Oncological Outcome of Transoral Laser Surgery in Laryngeal Carcinomas

AbstractThe principles of treatment of laryngeal carcinoma have undergone changes over the last few years and can be very complex with early (I-II) and advanced (III-IV) stage diseases to be differentiated. Recent emphasis is on organ preservation and laryngeal function. Transoral CO2laser surgery has become a standard surgical procedure not only in early stage I and II laryngeal carcinomas but also in advanced stage III cases in combination with postoperative adjuvante radiochemotherapy. This retrospective study reflects the role of transoral laser surgery as a single or multimodality treatment regime with neck dissection and postoperative radiochemotherapy in laryngeal carcinomas.From January 1997 to February 2007, 239 patients (215 men and 24 women; mean age 61 years) were examined with laryngeal squamous cell carcinoma (stage I-IV). 220 out of these 239 patients underwent transoral laser surgery, depending on their tumor stage either as a single or as a multimodality treatment regimen in combination with bilateral neck dissection and postoperative radio-chemotherapy. Thirteen patients underwent a transcervical tumor resection, 5 patients underwent radiochemotherapy alone and one patient refused a treatment of his tumor disease. Median follow-up time was 60 months.The 5-year overall survival rate of the 220 patients who were treated with laser surgery was 86%. The 5-year recurrence-free survival rate was 69.5%. After laser surgical interventions, postoperative complications occurred in 16%.The oncological outcome of transoral laser surgery as a single mode in early laryngeal carcinomas or in combination with bilateral neck dissection and postoperative adjuvant radiochemotherapy in advanced tumor stages is satisfying if clean surgical tumor margins (R0) can be reached. If tumor-free margins cannot be achieved (R1and R2resection) and transoral revision is not possible, transcervical procedures (total or partial laryngectomy) must be considered.

Transoral Robot‐Assisted CO2 Laser Supraglottic Laryngectomy: Experimental and Clinical Data

Transoral CO2 laser surgery for selected supraglottic tumors results in improved postoperative function and decreased morbidity, with comparable survival to open surgery. Recently, robot-assisted techniques have been reported for the management of supraglottic lesions. There are no reports in the English literature of robotic technology coupled with CO2 laser technology. Our objective was to report the use of such technology. Experimental resection of the supraglottis in a cadaver and a dog model using a commercially available surgical robot coupled with CO2 laser technology. Initial human experience with such technology is reported. With use of a hollow core fiber that allows the transmission of CO2 laser energy linked to the daVinci Surgical Robot, a supraglottic laryngectomy was performed in an edentulous female cadaver. The FK Laryngo-Pharyngoscope was used for exposure. In a second experiment, a supraglottic partial laryngectomy was performed in an 80 pound dog. On the basis of our experimental experience, a CO2 laser robotic-assisted supraglottic laryngectomy was attempted in three patients. Removal of the supraglottic larynx in both a cadaver and canine experimental models was believed to be satisfactory using this technology. Bleeding was easily controlled in the live canine model. A 74-year-old woman with a large supraglottic mass for which she had been offered a total laryngectomy was resected successfully with this technology. The FK Laryngo-Pharyngoscope provided excellent exposure. The patient was able to swallow without difficulty on postoperative day 5. Follow-up endoscopic examination at 1 month showed no evidence of residual laryngeal tumor. Robot-assisted procedures were attempted in two additional patients, but adequate exposure could not be achieved, and more traditional techniques were performed. The use of the daVinci Surgical robot coupled with CO2 laser technology is feasible, as demonstrated by our experimental and clinical data. Although further development of the robotic technology is required at present, the use of robotics coupled with CO2 laser technology may have important implications in the management of supraglottic laryngeal cancer in the future.

Carbon dioxide laser microsurgery for early glottic carcinoma

To define the oncologic efficacy of transoral endoscopic CO2 laser surgery in early glottic carcinoma. A retrospective study of 103 patients with glottic carcinoma (14 Tis, 68 pT1a, 14 pT1b, and 7 pT2) treated from October 1993 to June 2001. Surgical treatment included endoscopic CO2 laser cordectomies according to the classification of the European Laryngological Society. According to the Kaplan-Meier method, the probability of remaining free of local recurrence 5 years after primary surgery alone was 100% for the Tis, 96.05% for the T1, and 100% for the T2. Local control at 5 years after exclusive CO2 laser salvage surgery was 98.03%. The probability of remaining free of local recurrence 5 years after any type of salvage surgery was 100%. Laryngeal preservation was achieved in 100% of the cases. According to the present series, endoscopic CO2 laser surgery is an effective treatment for early glottic cancer. C-4.

CO2 laser surgery: a larynx preservation alternative for selected hypopharyngeal carcinomas.

Transoral CO2 laser surgery (TLS) has demonstrated good oncologic results and low morbidity in the treatment of selected laryngeal carcinomas, but experience in hypopharyngeal carcinomas (HC) is limited. The aim of this study was to evaluate the usefulness of TLS in the treatment of selected HC. Twenty-eight patients with HC were treated with TLS and neck dissection. Tumors with preoperative invasion of thyroid cartilage at CT, deep growth into the cervical space or tongue base, and tumors crossing the posterior midline or involving the cervical esophagus were excluded. Postoperative radiation to the neck was administered when more than one lymph node was involved, when the metastasis diameter was greater than 2 cm, or when extranodal spread was found at the pathologic study. The sample included two T1, 16 T2, nine T3, and one T4 tumors. Stage classification was: II, 21.4%; III, 28.6%; and IV, 50%. Four-year overall and disease-specific survival rates were 43.4% and 59.4%, respectively, with 78.5% function preservation. Nine patients (32.1%) did not need a nasogastric feeding tube. The mean duration of the feeding tube in the remaining patients was 15.27 +/- 27.3 days. We had two postoperative bleeding episodes that required endoscopic coagulation and three postoperative pneumonias caused by aspiration. TLS is an alternative for the treatment of selected HC associated with a high larynx preservation rate.

133 Transoral CO2 laser surgery for organ preservation in hypopharynx carcinomas

133 Transoral CO2 laser surgery for organ preservation in hypopharynx carcinomas

Complications in transoral CO2 laser surgery for carcinoma of the larynx and hypopharynx.

Because of the increase in indications for laser surgery to treat malignant tumors of the larynx and hypopharynx, a higher number of complications may be expected. We prospectively evaluated the frequency and characteristics of intraoperative and postoperative complications of early and advanced tumors of the larynx and hypopharynx treated with CO(2) laser surgery and the potential influence of the surgical learning curve on the complication rate. Two hundred seventy-five patients operated in a tertiary referral center. Complications were classified either as major, requiring intensive medical treatment, blood transfusion, surgery, or ICU admission, or minor, resolving spontaneously or with conventional ambulatory treatment without sequelae. The surgical learning curve was analyzed by dividing the patients into two groups according to the date of surgery and then comparing the number of complications. Complications occurred in 18.9% of patients; 9.8% were considered major and 9.1% minor. Complications included local infection (0.7%), emphysema (1%), cutaneous fistula (0.3%), postoperative bleeding (8%), airway ignition (0.3%), dyspnea (because of edema or stenosis) (1.8%), and swallowing difficulties or aspiration pneumonia (6.1%). The complication rate correlated significantly with tumor extension (p <.0001), the presence of diabetes mellitus (p =.01), and less surgical experience (p <.0001). Complications with severe sequelae occurred in two patients (p =.7). Complications after transoral laser surgery of larynx and hypopharynx carcinomas are relatively frequent (18.9%), but serious sequelae and mortality rate are low. Complications are associated with tumor extension, limited surgical experience, and diabetes mellitus.

Transoral CO2 laser for surgical management of glottic carcinoma in situ.

In carcinoma in situ (CIS) tumors malignant cells have not penetrated the basement membrane and therefore have no metastatic potential. Treatment strategies of CIS are topics of ongoing discussion. The aim of this study was to evaluate long-term results of CO2 laser therapy in laryngeal CIS. From 1986 to 1995, 29 patients with glottic CIS with a minimum follow-up of 2 years were treated initially with transoral CO2 laser surgery and were included is this series. A complete removal of the tumor was possible with superficial laser cordectomy in 21 patients and with subligamental laser cordectomy in 8 cases. There was no tumor-related death in this series. Repeated laser resections were performed in four patients for local recurrences. No patient required total laryngectomy or radiotherapy during a follow-up ranging from 25 to 143 months. Local control rates presented in this study are superior to those previously reported with conventional surgery and similar to those after radiotherapy. The ultimate rate of larynx preservation was seven times higher than reported after radiotherapy. Our results add further support to the observation that laser surgery is the best treatment option for CIS of the larynx. Based on the material of this study, recommended treatment for CIS is CO2 laser resection in combination with a meticulous follow-up for early recognition of local recurrence.