William C. Perry

Carcinoma of the Tongue Base Treated by Transoral Laser Microsurgery, Part One: Untreated Tumors, a Prospective Analysis of Oncologic and Functional Outcomes

Objectives: To report the oncologic and functional outcomes of transoral laser microsurgery (TLM) in the management of untreated primary carcinoma of the tongue base.

Oropharyngeal Cancer: A Case for Single Modality Treatment With Transoral Laser Microsurgery

OBJECTIVE To demonstrate the role of transoral laser microsurgery (TLM) in the treatment of oropharyngeal cancer. DESIGN A 2-center retrospective case series analysis. SETTING Two tertiary care medical centers. PATIENTS The study population comprised 69 patients with previously untreated select T1 to T3, N0 to N2 squamous cell carcinoma of the oropharynx, of whom 44 (74%) had no indication for adjuvant RT and 25 (36%) had an indication for adjuvant RT to the neck alone but declined radiotherapy. The primary tumor sites were the tonsil (n = 28 [41%]), tongue base (n = 28 [41%]), pharyngeal wall (n = 8 [12%]), soft palate (n = 4 [6%]), and vallecula (n = 1 [1%]). INTERVENTIONS Transoral laser microsurgery in 69 patients, with neck dissection in 59 patients (83%). MAIN OUTCOME MEASURES Complications, local and regional control, overall and disease-specific survival, swallow function, and feeding tube dependence. RESULTS Over the mean follow-up period of 44 months, 66 of 69 patients had no disease recurrence at the primary site. The 5-year local control estimate was 94%. The mean duration of hospitalization was 3 days. There were no major complications relating to TLM. No patient required a permanent feeding or tracheostomy tube. For stage I, II, and III disease, the 5-year Kaplan-Meier estimates of locoregional control were 90%, 73%, and 70%, respectively. The 5-year overall survival estimate was 86%. CONCLUSIONS Transoral laser microsurgery alone with or without neck dissection is an effective approach for select T1 to T3, N0, or N1 oropharyngeal cancer. Low levels of morbidity, short treatment duration, and excellent disease control make it an attractive therapeutic strategy. The treatment option of endoscopic-assisted laser microsurgery should be discussed by the multidisciplinary team for patients presenting with tumors suitable for this approach.

Transoral laser microsurgery for carcinoma of the supraglottic larynx

Objectives The study goal was to report the oncologic outcomes of transoral laser microsurgery (TLM) in the treatment of squamous cell carcinoma of the supraglottic larynx. Study Design and Setting A two-center prospective case series analysis. Results Thirty-eight patients underwent TLM for previously untreated carcinoma of the supraglottic larynx between 1997 and 2005. Pathological T stages were T1 in 8 (21%), T2 in 14 (37%), T3 in 8 (21%), and T4 in 8 (21%). Twenty-six patients (68%) had neck dissections. Thirteen patients (34%) received adjuvant radiotherapy. The mean follow-up for all patients was 31 months. The 2-year Kaplan-Meier estimates for local control were 97%; locore-gional control, 94%; disease-specific survival, 80%; and overall survival, 85%. The overall functional laryngeal preservation rate was 79% (19 of 24). Conclusions TLM is a safe and effective treatment for cancer of the supraglottic larynx Significance TLM is an emerging strategy in the management of laryngeal cancer.

Transoral laser microsurgery for recurrent laryngeal and pharyngeal cancer

Study Design and Setting A two-center prospective case series analysis. Patients One hundred fourteen patients with previously treated laryngeal or pharyngeal squamous cell carcinoma who underwent salvage transoral laser microsurgery (TLM). Interventions TLM in 114 patients, neck dissection in 22 (19%) patients, adjuvant radiotherapy in 12 (11%) patients. Results Ninety-one (80%) patients had recurrent primary tumors whereas 23 (20%) patients had second primary tumors occur within a previously irradiated field. The minimum follow-up was 1 year (median, 3 years). The distribution of tumor location was oropharynx 52 (46%), glottic and subglottic larynx 44 (39%), supraglottic larynx 11 (10%), and pyriform/hypopharynx 7 (6%). Overall, three-year local and locoregional control estimates were 70 percent and 67 percent, respectively; and three-year survival and disease-free survival estimates were 62 percent and 64 percent, respectively. The average duration of hospitalization was 2.3 days. Four (3.5%) patients had significant postoperative bleeding. Two (<2%) patients had treatment-related deaths. Conclusions Transoral laser microsurgery offers select patients an attractive alternative salvage surgical therapy to the recurrent and second primary tumor site.

Transoral Laser Microsurgery for Untreated Glottic Carcinoma

OBJECTIVES: To report the oncology and functional outcomes of transoral laser microsurgery (TLM) for untreated glottic carcinoma. STUDY DESIGN: A 2 center prospective case series analysis. SETTING: Academic, tertiary referral centers. RESULTS: Seventy-six patients underwent TLM. Pathologic T stages were: T1, 45 (59%); T2, 21 (28%); T3, 5 (7%); and T4, 5 (7%). Five (7%) patients had neck dissections. Five (7%) patients received adjuvant radiotherapy. Mean follow-up was 42 months. Respective T1 and T2 5-year Kaplan-Meier estimates were: local control, 90% and 93%; loco-regional control, 90% and 93%; disease specific survival, 90% and 93%; and overall survival, 94% and 93%. The average hospital stay was 2 days. Two (3%) patients experienced major complications. The overall laryngeal preservation rate was 95% (72 of 76). CONCLUSIONS: TLM is a safe and effective treatment in select carcinoma of the glottic larynx. Low morbidity and mortality and short periods of hospitalization make TLM an attractive therapeutic option. SIGNIFICANCE: TLM is an emerging strategy in the treatment of laryngeal cancer.

Carcinoma of the tongue base treated by transoral laser microsurgery, part two: Persistent, recurrent and second primary tumors.

Objectives: To report the oncologic and functional outcomes of transoral laser microsurgery (TLM) in the treatment of persistent, recurrent, and second primary squamous cell carcinoma of the tongue base.

Relapse patterns after transoral laser microsurgery and postoperative irradiation for squamous cell carcinomas of the tonsil and tongue base.

Objectives: We evaluated relapse patterns after transoral laser microsurgery (TLM) in squamous cell carcinoma (SCC) of the tonsil and tongue base and evaluated the indications for adjuvant irradiation. Methods: Between December 1, 1996, and December 31, 2005, 79 patients with previously untreated SCC of the tonsil or tongue base underwent TLM with or without neck dissection. Thirty-eight patients (48%) underwent postoperative irradiation (median, 62 Gy) to the primary site and the neck. Analysis of relapse patterns was performed on the basis of adverse risk factors and the presence or absence of adjuvant irradiation. Results: The median follow-up for living patients was 47 months (range, 10 to 107 months), and patients were monitored for at least 2 years or until recurrence or death. Local, regional, and distant treatment failures numbered 4, 6, and 4 for surgery alone (n = 41) and 0, 2, and 6 for adjuvant irradiation (n = 38), respectively. Patients with high-risk features (extracapsular extension or at least 2 adverse factors) had locoregional control rates at 2 or more years of 66% and 94% for TLM alone and TLM plus adjuvant irradiation, respectively. Conclusions: Adjuvant irradiation after TLM resection of oropharyngeal SCC with intermediate- or high-risk features improves locoregional control compared with TLM alone.

In reference to Effective Use of Physician Extenders in an Outpatient Otolaryngology Setting

We recently reviewed the article ‘‘Effective Use of Physician Extenders in an Outpatient Otolaryngology Setting.’’ This article was of particular interest as we currently employ five highly skilled, fellowship-trained, otolaryngology/head and neck surgery physician assistants (PAs) in our practice. PAs have, as a profession, rejected calls to seek independent licensing, believing in a collaborative physician-led model of care. This decision, from the inception of the profession, places the care of the patient as the foremost goal of a skilled team. In our multispecialty, academic, tertiary care setting, PAs have proven to be an extremely valuable asset. They function, as noted in the article, from a collaborative to a near independent role. Like the article, we believe that the role of ‘‘scribe’’ should be limited to a medical assistant or trainee. PA responsibilities embody the three-shield model at Mayo Clinic: patient care, education, and research. PAs are first assistants in surgery, as well as responsible for both inpatient and outpatient care. They maintain an independent clinic appointment list, seeking consultation when necessary, and billing under their own Medicare number. This allows improved access into our department from in-house referral, as well as delegation of select postsurgical care. They are preceptors for PAs in training as well as residents in our institution. PAs are also deeply involved in many clinical research projects within our department and institution. Under the section Future Directions in the abovementioned article, there is reference to postgraduate training programs for PAs. The authors state that there are no such training programs in otolaryngology. Although this may be correct for nurse practitioners, this is not accurate for the PA professional. Mayo Clinic Arizona is currently in the sixth year of our postgraduate fellowship for PAs in otolaryngology/head and neck surgery. This 12-month fellowship includes subspecialty rotations in head and neck surgery; laryngology; rhinology; facial plastic surgery; endoscopic skull base surgery; oral and maxillofacial surgery; neurotology; pediatric ear, nose, and throat (ENT); medical ENT; audiology, radiation oncology, and the intensive care unit. Our fellows graduate with extensive surgical experience as well as inpatient and outpatient training. Our fellowship is under review for national accreditation through the Accreditation Review Commission on Education for the Physician Assistant, and beginning in 2012 will expand to two fellows per year. Past fellows are currently employed in both academic and communitybased practices. Further information may be obtained through contacting Carrlene Donald, MMS, PA-C, Program Director, at donald.carrlene@mayo.edu. Thank you for your time.

08:02: Recurrent Laryngeal and Pharyngeal Cancer Salvaged with TLM

OBJECTIVES: 1. Understand the role of Transoral Laser Microsurgery in the management of recurrent cancer of the larynx and pharynx. 2. Describe the outcomes and complications following salvage TLM for recurrent larynx and pharynx cancer. METHODS: Study Design and Setting: A two-center prospective case series analysis. Patients: One hundred and sixty-four patients undergoing salvage Transoral Laser Microsurgery (TLM) for previously treated laryngeal or pharyngeal squamous cell carcinoma between 1996 and 2006. Interventions: TLM in 164 patients, neck dissection in 35 and adjuvant radiotherapy in 17 patients. Outcome measures: End points analyzed included overall survival, disease-free survival, local control, locoregional control, duration of hospital stay and complications. RESULTS: One hundred and nine patients (67%) had salvage TLM for recurrent primary tumors while 55 patients (33%) had salvage TLM for new primary tumors occurring within a previously treated region. The average follow-up period was 26 months. The distribution of tumor location was oropharynx 75 (46%), glottic and subglottic larynx 57 (35%), supraglottic larynx 19 (12%), pyriform hypopharynx 11 (7%), hypopharynx and cervical esophagus 2 (1%). Overall two-year local and locoregional control estimates were 75% and 72%, respectively. Two-year disease-free and overall survival estimates were both 70%. The 5-year Kaplan-Meier estimates were: local control, 71%; locoregional control, 68%; disease-free survival 63% and overall survival 59%. The average duration of hospitalization for all patients was two days. Five patients (3%) suffered significant postoperative bleeding. CONCLUSIONS: Transoral Laser Microsurgery offers select patients an attractive salvage surgical therapy to the recurrent tumor site. 08:10 Racial Patterns of Thyroid Cancer Incidence in the U.S. Luc GT Morris, MD (presenter); Andrew Sikora, MD, PhD; Daniel Jethanamest, MD; Mark D DeLacure, MD