Petra Ambrosch

Organ Preservation by Transoral Laser Microsurgery in Piriform Sinus Carcinoma

OBJECTIVE: To determine the effectiveness of organ-preserving CO2 laser microsurgery for the treatment of piriform sinus carcinoma. METHODS: A retrospective review of 129 previously untreated patients undergoing CO2 laser microsurgery for the treatment of squamous cell carcinomas of the piriform sinus from 1981 to December 1996 was undertaken. The intention was complete tumor removal by preserving functionally important structures of the larynx. Distribution of tumors (Union Internationale Contre le Cancer/American Joint Committee on Cancer, 1992) was 24 cases with pT1, 74 with pT2, 17 with pT3, and 14 with pT4 disease. Node status was positive in 68% of patients. Seventy-five percent of patients had stage III or IV disease. Forty-two percent of the patients were treated solely with surgery, and 58% had surgery and postoperative radiotherapy. The median follow-up interval was 44 months. RESULTS: Eighty-seven percent of patients were controlled locally. Neck recurrences occurred in 14.0% of patients, metachronous distant metastases with locoregional control in 6.2%, and second primary tumors in 18.6%. Twenty percent of patients died of TNM-related deaths. The 5-year overall Kaplan-Meier survival rate was 71% for stages I and II and 47% for stages III and IV disease; the 5-year recurrence-free survival rates were 95% and 69%, respectively. CONCLUSION: A comparatively low local recurrence rate, a high recurrence-free survival rate, and the avoidance of laryngectomy favor function-preserving surgery of piriform sinus carcinomas. (Otolaryngol Head Neck Surg 2001; 124:58-67.)

Carbon Dioxide Laser Microsurgery for Early Supraglottic Carcinoma

Forty-eight untreated patients with early supraglottic carcinoma (12 patients stage I and 36 patients stage II) had primary carbon dioxide laser microsurgery between 1979 and 1994 with the intent of complete tumor removal with preservation of functionally important structures of the larynx. Ninety-six percent of the patients were treated exclusively by surgery; 4% had laser microsurgery and postoperative radiotherapy. With a median follow-up of 55 months, the 5-year local control rate with the first treatment was 100% for pT1 cases and 89% for pT2 cases. The ultimate local control rate with voice preservation, including patients successfully salvaged after a local recurrence, was 97% for pT2 carcinomas. Five (10%) patients died of tumor (TNM)–related deaths. The 3-year recurrence-free rate and 3-year overall survival rate (Kaplan-Meier) were 87% and 85%; the 5-year recurrence-free rate and 5-year overall survival rate were 83% and 76%, respectively. The results achieved with transoral laser microsurgery in early supraglottic carcinoma are comparable to those of open supraglottic laryngectomy with respect to local control and survival. The functional results are superior, since clinically relevant aspiration did not occur.

Efficacy of Selective Neck Dissection: A Review of 503 Cases of Elective and Therapeutic Treatment of the Neck in Squamous Cell Carcinoma of the Upper Aerodigestive Tract

OBJECTIVE: The purpose of this study was to evaluate the efficacy of selective neck dissection (SND) in elective and therapeutic treatment of the neck. METHODS: A retrospective review was undertaken of 503 previously untreated patients undergoing 711 SNDs as a part of initial therapy for squamous cell carcinoma of the larynx, oral cavity, oropharynx, and hypopharynx from August 1986 to June 1997 at a single institution. Lymph nodes were pathologically negative in 249 and positive in 254 patients. Postoperative radiotherapy was given to 14.5% of the node-negative and 62.2% of the node-positive patients. The median follow-up interval was 41 months. RESULTS: The 3-year regional recurrence rates estimated according to Kaplan-Meier were as follows: pN0, 4.7%; pN1, 4.9%; pN2, 12.1%. A comparison of recurrence rates with respect to the extent of neck disease and postoperative radiotherapy demonstrated a tendency to an improved regional control in irradiated patients with one metastasis and a distinctly improved regional control in patients with multiple metastases or metastases with extracapsular spread. CONCLUSION: The results achieved with SND compare favorably with the results reported for modified radical neck dissection. The application of SND might be extended to more advanced neck disease.

Transoral carbon dioxide laser microsurgery for recurrent glottic carcinoma after radiotherapy

Transoral laser microsurgery is successfully performed in the treatment of primary laryngeal carcinomas. Few publications deal with the application in patients with recurrent glottic carcinomas after radiation failure. Our study aims to review our experience with transoral laser microsurgery in these patients.

Selective neck dissection in the management of squamous cell carcinoma of the upper digestive tract.

Selective neck dissection has been used clinically in elective treatment of carcinoma, although many surgeons continue to advocate modified radical or radical neck dissection for therapeutic management of the neck. In a retrospective study 167 previously untreated patients were reviewed following curative laser microsurgical resections of oral or pharyngeal primary tumors and a unior bilateral selective neck dissection. In all, 221 (54 bilateral) neck dissections were performed. In patients with oral primary disease lymph nodes of levels I–III were removed, while nodes in levels II and III were removed in patients with pharyngeal tumors. Level IV was dissected when several metastases were suspected during operation. The posterior triangle was not dissected. Lymph nodes were histopathologically negative in 73 patients and positive in 94 patients. Twenty-five of these latter cases had pN1 disease, 55 had pN2b disease and 10 had bilateral lymph node metastases. Twenty patients in the pN0 group and 63 patients in the pN+ group received postoperative radiotherapy (to 56.7 Gy to the primary site and 52.5 Gy to the neck). With a median follow-up interval of 34 months, recurrence in the dissected neck occurred in 3 of 73 patients (4.1%) with pN0 disease and 6 of 90 patients (6.6%) with pN+ necks. Four patients with pN+ necks had simultaneous recurrences at the primary site. The addition of adjuvant radiotherapy seemed to improve disease control in the neck and improve overall survival in patients with an unfavorable prognosis due to multiple metastases or metastases with extracapsular spread.

Transoral laser surgery for supraglottic cancer.

The goal of treatment for supraglottic cancer is to achieve cure and to preserve laryngeal function. Organ preservation strategies include both endoscopic and open surgical approaches as well as radiation and chemotherapy. The challenge is to select the correct modalities for each patient. Endoscopic procedures should be limited to tumors that can be completely visualized during diagnostic microlaryngoscopy. If complete resection can be achieved, the oncologic results of transoral laser surgery appear to be comparable to those of classic supraglottic laryngectomy. In addition, functional results of transoral laser resection are superior to those of the conventional open approach, in terms of the time required to restore swallowing, tracheotomy rate, incidence of pharyngocutaneous fistulae, and shorter hospital stay. The management of the neck remains of paramount importance, as survival of patients with supraglottic cancer depends more on cervical metastasis than on the primary tumor. Most authors advocate bilateral elective neck dissection. However, in selected cases (T1,T2 clinically negative [N0] lateral supraglottic cancers), ipsilateral selective neck dissection could be performed without compromising survival. The authors conclude that with careful selection of patients, laser supraglottic laryngectomy is a suitable, and often the preferred, treatment option for supraglottic cancer.

p16 alterations and retinoblastoma protein expression in squamous cell carcinoma and neighboring dysplasia from the upper aerodigestive tract.

Abstract. The progression potential of preinvasive epithelial lesions is usually evaluated by assessing the degree of histologic dysplasia. We examined p16, retinoblastoma protein (pRb), and proliferating cell nuclear antigen (PCNA) immunophenotypes in 57 cases of previously untreated squamous cell carcinoma (SCC) of the upper digestive tract and in the neighboring normal and dysplastic epithelia. Tissue samples were examined for homozygous deletion of exon 2 of the p16 gene using polymerase chain reaction (PCR) analysis. The PCNA index increased with increasing grade of dysplasia. The pRb protein was expressed in 89% of the samples of SCCs and in the neighboring dysplasias and carcinoma in situ (CIS). In cases with a lack of pRb expression, corresponding preinvasive lesions were also negative. Lack of p16 expression was found in 82% of SCCs. The prevalence of p16 expression decreased with increasing grade of dysplasia. Molecular analysis of the p16 gene showed homozygous deletion in 37% of SCCs, 33% of CIS, and 15% of the samples of normal epithelia. Our data indicate that inactivation of p16 may play an important role in early head and neck carcinogenesis, whereas the mutation of Rb may be an infrequent event. The p16 immunophenotype might be a biomarker for an increased risk of progression in squamous dysplasia.

Clinical staging of oropharyngeal carcinoma

An alternative to the International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) stage grouping system was proposed for patients with oropharyngeal carcinoma by Hart et al. (1995) on behalf of the Dutch Head and Neck Oncology Cooperative Group. The system was created by regrouping the T, N, and M categories without redefining the categories themselves.

Value of postoperative radiotherapy in patients with pathologic N1 neck disease

The aim of this study was to assess the efficacy of postoperative radiotherapy for the treatment of patients with pathologic N1 neck disease.

Komplikationen nach transoraler Lasermikrochirurgie von Mundhöhlen-, Rachen- und Kehlkopfkarzinomen

Zwischen August 1986 und Dezember 1994 wurden an der GOttinger UniversitAts-HNO-Klinik 704 Patienten mit nicht vorbehandelten Plattenepithelkarzinomen aller T-Kategorien der MundhOhle (n = 101), des Oro- (n = 140) und des Hypopharynx (n = 98) sowie des Larynx (n = 365) lasermikrochirurgisch in kurativer Absicht operiert. Es traten folgende Komplikationen auf: FUnf Patienten hatten aufgrund vorbestehender Erkrankungen verschiedene kardiale und pulmonale Komplikationen. 22 von 704 Patienten (3,1%) hatten eine postoperative Nachblutung aus dem Resektionsbereich. Nach der Resektion von MundhOhlenkarzinomen traten in 3,9%, nach der Resektion von Oropharynxkarzinomen in 6,4% und nach der Resektion von Hypopharynx-karzinomen in 3,0% der FAlle Nachblutungen auf. Keiner der Patienten mit Stimmlippenkarzinomen hatte eine Nachblutung, wAhrend nach supraglottischer Larynxteilresektion in 7,0% der FAlle Nachblutungen beobachtet wurden. In 19 Fallen wurde die Blutung durch Elektrokoagulation oder durch GefAssunterbindung gestillt, in 3 Fallen war die Ligatur der Arteria carotis externa am Hals erforderlich. Drei Patienten wurden wegen atemrelevanter Odeme nach ausgedehnter Larynxteilresektion mehrere Tage mit Glukokortikoiden behandelt. Bei 2 weiteren Patienten wurde Schleimhaut, die die Glottis verlegte, lasermikrochirurgisch abgetragen. Bei einem Patienten trat nach Resektion eines Hypopharynxkarzinoms ein Abszess im Resektionsbereich auf. Nach ausgedehnter Larynx-Pharynx-Teilresektion wurden 3 Patienten wegen Aspiration passager tracheotomiert, und 1 Patient musste aus funktionellen GrUnden laryngektomiert werden.