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  • Patients with DLE had a fold higher rate of

    2019-04-15

    Patients with DLE had a 4.6-fold higher rate of local recurrence than those without DLE. The 5-year local control rates were 20% and 91% in patients with and without DLE, respectively. DLE creates serious problems not only in inserting the endotracheal tube but also in performing MLS in patients under general anesthesia. The condition may result from anatomic characteristics or trauma to the neck, and prevent visualization of the glottis. Patients with limited mouth opening, a receding lower jaw, a short or stiff neck, marked obesity, or a large tongue may also be at high risk of DLE. However, such problems can be difficult to predict preoperatively. Although rigid laryngoscopes and specialized surgical instruments have been developed for use in patients with DLE, it is still difficult to expose the anterior commissure of the vocal fold for TLM. Zeitels and Vaughan reported that the use of both external counter-pressure and internal distention as an adjunct to microlaryngoscopy may be helpful in the surgical management of lesions located near the anterior commissure. However, if these methods cannot achieve an adequate surgical margin, postoperative RT is recommended. Patients with previous MLS by simple removal of the mucous membrane (mucosal stripping) before TLM had a 3.1-fold higher rate of local recurrence than those without a previous biopsy. The 5-year local control rates were 67% and 94% in patients with and without a previous biopsy before TLM, respectively. In our series, most of the patients (15/17) with a previous biopsy were referred from local hospitals. The biopsy was performed with small or no surgical margin by cold instruments or a CO2 laser. It was therefore more difficult to identify the margin during TLM in these patients due to histamine receptor antagonist or scarring of the surgical bed. In our experience and according to the recommendations of other studies, both biopsy and treatment can be accomplished in one endoscopic procedure. When malignancy is strongly suspected, resection with margin exceeding 1 mm is oncologically adequate. Such patients do not need to receive a second surgery under general anesthesia, thus reducing surgical time, cost of treatment, and trauma. Therefore, for those patients with minimally invasive carcinoma of the vocal fold, resection with type I or type II cordectomy performed simultaneously during biopsy is recommended for both diagnosis and treatment. No significant differences have been reported in vocal parameters between patients undergoing subepithelial cordectomies (type I), subligamental cordectomies (type II), and controls. Patients with positive surgical margin had a 2.7-fold higher rate of local recurrence than those with negative margin. The 5-year local control rates were 56% and 92% in those with positive and negative margin, respectively. These findings are similar to those of previous studies which reported 5-year local control rates of positive margin ranging from 51.3% to 81.9%, and negative margin from 78.4% to 95%. Local recurrence has been reported to be significantly correlated with the presence of positive margin. The management of positive margin after TLM depends on institutional policy, and repeated TLM, postoperative RT and watchful observation are all reasonable treatments after TLM. Laser re-excision is suggested by most studies at 2 weeks to 6 months postoperatively. RT can be administered in cases with more than 2 positive margins, persistent positive margin after repeated TLM, paraglottic space involvement or upon the patient\'s preference. If experienced surgeons have confidence in the safety of the margin during TLM, watchful observation is another way to manage positive margin after TLM. However, watchful observation is suggested for patients with good compliance who receive close and regular follow up. In our institute, watchful observation is our policy for positive margin if the surgeon has confidence and patients have good compliance. Regardless of whether patients receive a second operation or adjuvant RT, the local recurrence rate has still been reported to be higher than for those with negative margin. Therefore, binary fission is important to provide wide resection of the primary tumor with adequate margin during the first surgery. Removal of large glottic tumors by en bloc resection is not necessary. Transecting tumors by the piecemeal method may be useful in evaluating deep margin. The carbonization of tumors after cutting by CO2 laser is different from the carbonization of normal mucosa and submucosa of the glottis. This difference may suggest that laser surgery can be used to recognize the contours of glottic tumors and obtain adequate margin.