In July of 1996, eight American surgeons traveled to Göttingen, Germany to learn more about the laser techniques of Professor Wolfgang Steiner. Using a CO2 laser beam, he was ablating larynx and pharynx cancers working only through the mouth. His reported disease control rates and functional restoration reports equaled the best open surgery could produce. He challenged us to reassess our open surgery concepts, and offered to teach his techniques. It was hard to imagine patients undergoing laser resection through the labyrinthine passageways of the head and neck with the technology we were used to here. Why would such a limited approach even be considered? How could he see properly, control bleeding, avoid cancer spillage, or reconstruct the defect?
Skeptical but curious, we paid attention as Professor Steiner demonstrated and explained. What we found in Germany was convincing documentation of the safety and efficacy of endoscopic laser resection of larynx and pharynx cancers that would rarely be treated without larger open operations in this country. Cure rates were as good as those obtained at any of the American institutions represented. But it was the lower treatment morbidity and the superior rehabilitative results that impressed us. Patients who would likely have lost much of their speech or voice with conventional surgery were speaking. Patients who would have had to accept a tracheostomy to lose their cancer had none. Swallowing was preserved in patients we expected might lose it. The risks of treatment appeared less, hospitalization time was reduced, and when the tumor was successfully cured, the quality of life was superior. Ironically, the lasers used in Göttingen were American made. But the program developed around them is what made the difference, and the implications for patients here in the United States are exciting.
Head and neck cancer is about 5% of US cancer. The most frequent cell type is squamous cell carcinoma, which usually begins on the mucosal surfaces of the larynx, the pharynx, or the oral cavity. The primary tumor is accessible to endoscopic instrumentation, but in all but the smallest tumors, endoscopes are considered useful only as diagnostic tools. Conventional laryngoscopes can expose selected small (T1) vocal cord cancers for biopsy and removal, but a typical T3 larynx cancer, surrounded by a safe cuff of normal tissue, would be too big to extract through an endoscope. Without open access, bleeding would be difficult to control and if blood obscures a tumor's margins during removal, the effect of the resection is jeopardized.
With the exception of early vocal cord carcinomas, most head and neck cancers metastasize to cervical lymph nodes. Small cell clusters penetrate local lymphatic channels and embolize along those passageways to become trapped in cervical lymph nodes. There they silently multiply, producing a malignant lateral neck mass capable of further metastasis itself. Fortunately, lymph node metastases are usually operable, but the primary tumor, (the source of further tumor emboli), must be controlled.
Despite great strides in non-operative therapy, more cancers are still cured by surgery than any other treatment. Open operations are well established for head and neck cancers, but their effects on the patient can be devastating. This knowledge impacts treatment. If we conserve neighboring tissues in the hopes of sparing voice or nasal breathing, we increase the risk recurrence. If we extend the excision to control this risk, the patient requires elaborate and costly reconstruction. Our best reconstructions only partially deal with lost functions.
The typical patient undergoing conventional surgical treatment for larynx cancer has a tumor too big to expect cure by radiotherapy. It threatens the neck with metastasis. Surgery usually begins with an endoscopic examination to fix the tumor extent firmly in mind. We open the neck, disassemble its muscles, nerves, and vascular structures, and expose the pharynx and larynx for resection.
On the way, the lymph nodes are removed. Approaching the cancer from its deep side (blind side), we enter the aerodigestive tract and remove all the tissue judged to contain the cancer, plus a surrounding zone of normal tissue. Following Halsted's en bloc principle, this specimen is always removed in one piece. With the specimen out and the margins reported free, we advance the edges of the defect to separate the throat from the neck. If the defect is too large, we bring in a flap from the chest. We reassemble the remaining neck structures over a drain, close the skin wound, and perform a tracheotomy to preserve the airway. A feeding tube is placed in the stomach.
"Minimally-invasive" treatment removes the same cancer, but we reach it thru natural passageways, i.e. through the mouth. Special open distendable laryngoscopes expose the cancer, which remains visible throughout the operation. The CO2 laser cutting beam is directed with a micromanipulator fixed to a surgical microscope, while the tumor is drawn one way or another with a special laryngeal grasping forceps. The object is to follow the tumor - we don't duplicate the "standard" operations. The tumor is divided into manageable subunits with the laser beam. Each unit is exposed and removed by laser-excision, so step by step the cancer is completely excised. The safety zone or margin of normal tissue excised can be tailored to suit the tumor. Once the excision is complete (margins negative) we are done. We make no attempt to close over the wound or introduce a flap.
Several weeks later, we perform a "second look" laryngoscopy. Granulation is removed (by laser) if excessive and submitted for biopsy. This provides the earliest possible detection of persistence, anywhere at the primary site. It provides a "second chance" for the patient with an impending recurrence — it can be removed with the laser at this time.
If a neck dissection is indicated, this is usually the time we do it. The patient has recovered from the laser excision, and is ready to face a selective conservation neck dissection, uncontaminated into the pharynx. Since there is no need to enter into the aerodigestive tract, we have eliminated the risk of a fistula, a dental organism soft tissue infection, and a host of other complications. Under these conditions, neck dissection is a predictable procedure, with an expected hospitalization of only four days.
Professor Steiner shared a large number of technical innovations with his guests but the two most important concepts that struck me as important were these:
1. Cutting through the tumor is essential and permissible;
2. Don't reproduce the open operations: follow the tumor
"Minimally-invasive" excisions violate Halsted's principle of "en bloc" resection. But the laser rescinds this principle. The coherent light energy from a CO2 laser is absorbed by cellular water and converted into heat. A suitably configured CO2 laser beam boils and seals the surfaces it exposes. Thus, the tumor can be cut up into manageable pieces for extraction without disseminating cancer.
Microspot laser focusing devices allow tissue division at very low wattages (2 W). At these power densities we can incise tissues with minimal carbonization. This enables the surgeon to observe the fine textural details of the normal tissues surrounding a tumor as the cutting proceeds. This is why we can tailor a custom resection exactly to the individual tumor - there's no char to obscure the details.
Head and neck tumors never grow as a homogeneous sphere. They follow the surrounding micro-anatomy. Some invade muscle but not cartilage, others follow perineural spaces, and others infiltrate the submucosa. Each tumor seems unique, especially in its character of invasion. All these procedures require a microscope, similar to the one used for otologic surgery. The microscope provides a new and improved view of the invasive interactions between each individual tumor and its environment. Subtle digressions can be recognized and followed as the cancer requires.
An second powerful bonus of the microscope is the opportunity it introduces for video display of the surgery. The assistant can see what the surgeon sees, offsetting the fact that endoscopic access is truly minimal. This translates into help from the assistant, who improves the exposure, passes the proper suctions, and supplies a "third hand" as necessary.
The "quality control officer" in head and neck surgery is a frozen section histopathologist. Initially, it was feared that laser coagulation would obscure the histopathology of margins, or that specimens would be lost to vaporization. This is a resection technique, not vaporization. The spread of collateral heat from a 2 watt microspot incision is minimal. A 3 or 4 cell layer thickness is denatured for pathology, not enough to complicate the margin calls, and the main tumor histopathology is fully preserved. What minimal collateral heat does occur is just enough to "seal" the cut surfaces. On the patient side, the tissue transsection is bloodless and basically sterile. The seal lasts about 5 days. Since there is no coagulum, chemo-attraction of cells that release the pain mediators in conventional wound healing is minimized.
Laryngeal cancer is highly curable (by excision); quality of life is the big issue. Potential threats include loss of the voice, a permanent stoma, and aspiration or progressive dysphagia. Minimally invasive laser resection ensures the maximum preservation of tissue needed to produce a phonatory source. It keeps the laryngeal skeletal framework intact, to support the airway open and avert dependence on a stoma.
Pharynx cancer is more aggressive than larynx cancer, and failure is usually local. Treatment programs are severe, usually requiring surgery and radiotherapy. The major quality of life issues are dysphagia and/or aspiration, voice loss, a permanent stoma, and cosmesis.
Minimally invasive laser resection encourages the optimum preservation of pharyngeal soft tissue. This reduces our dependence on major flap reconstructions, and conserves neighboring tissues to valve the airway during deglutition. The patient gains reduced risk, a shorter hospital stay, and the earlier return of swallow.
Mouth cancer shares with pharynx cancer the discouraging characteristic that recurrence is often local. Major quality of life issues relate to the impact of glossectomy and mandibulectomy on eating food, generating intelligible speech, swallowing without aspiration, and the appearance of the lower face and neck.
Minimally invasive laser resection ensures the maximum preservation of oral soft tissue and thus the lubrication and mobility that only non-irradiated mucosa can supply. There is no need to divide the jaw for access. We maximize our chance to produce an articulating tongue, and facilitate the recovery of swallow.
Microscopic excision provides the most reliable staging information we can obtain — we can know the depth of invasion exactly. Study of the laser-excised specimen also allows the lymphangio-invasive and neuro-invasive character of the primary to become known. For these reasons, minimally-invasive laser resection may provide an indication for neck dissection before neck node disease is clinically evident.
Similarly, the findings at laser excision may provide a reprieve from or the indication for radiotherapy. Some bulky tumors turn out to be quite superficial, and some small tumors have iceberg extensions. If the surgeon can be confident a superficial tumor is locally excised and there is little chance of neck disease, there is no need to invoke radiotherapy.
Additional treatment is common in our series of patients, as many had local or neck indications for radiotherapy or neck dissection. The commonest contraindication to adjuvant radiation therapy was the fact it had previously been given. Prior radiotherapy has been the single most cogent factor in delayed wound healing or local treatment failure. On the other hand, post laser radiotherapy is well tolerated in previously untreated patients.
After returning from Germany, an inter-institutional laser study group was organized to encourage all members of the original visiting surgeon's group to share their clinical experiences. It meets twice a year, and is organizing a follow-up database.
In August of 1996, St Lukes Hospital purchased the instruments and equipment needed to replicate the technology we witnessed in Gottingen. A strong laser safety and equipment support program was already in place. The systems, and necessary in house education to add this service were completed in August. Patients facing the usual surgical and radiotherapeudic options for new or recurrent head and neck cancers have been offered this option since September of 1996.
By April 10th, 1997, the first 27 Jacksonville cases had been treated. The feasibility and efficacy of this approach seemed substantiated, with a lower morbidity and shorter length of stay and than would otherwise have been expected. In November 97, my colleague, Dr John Salassa traveled to Gottingen. He brought back important new information to enhance this program, and is expanding patient access to this service at St Lukes Hospital.
Our relative indications for minimally-invasive transoral laser resection are listed in Table 1. These are not absolute — there are too many tumor and patient related variables. Case by case selection is required. For example, in some instances we have been asked to treat a local growth of tumor for palliation when distant metastases were already present. Also, the laser option can reduce one formidable high-risk head and neck operation into two smaller more tolerable procedures. Therefore, we have considered it in some patients where "surgery" was said to be contraindicated for general health reasons.
A demographic synopsis of the first 47 patients we have treated as of early January 1997 is presented in Table 2. The follow up is too short and the patient population too heterogeneous to use our data for outcomes. The original "visiting surgeons" group plans to pool what we learn over time, and in this way accelerate the feedback on survival and quality of life.
Minimally invasive laser resection is not limited to the larynx, pharynx, or mouth or strictly to squamous cell cancer. Here in Jacksonville, we have treated cancer at other sites such as the sinuses, the skin, and the ear. Non-squamous cancer types have included melanoma, sarcoma, adenoid cystic carcinoma, and a carcinoid tumor of the larynx. We have even appreciated a non-cancer benefit since acquiring this technology. We feel better equipped now for endoscopic laser Zenker's diverticulectomy, and laser arytenoidectomy for example.
At the present time, minimally invasive laser surgery for medium and large head and neck cancers is not yet offered at most US centers. If our own experience is any guide, this will gradually change. Casual scrutiny of the German literature and devotion to the Halsted imperative (not to cut tumors) will probably delay but not extinguish wider availability of this option. It seems this is treatment we should offer. Hopefully the data from Jacksonville and other centers will be more complete and supportive by the millenium. This may provide a basis for correcting the problem of broader access.
Suggested Reading
Steiner W. "Results of curative laser microsurgery of laryngeal car-cinomas." American Journal of Otolaryngology. 1993; 14(2): 116-21.
Steiner W. [Therapy of hypo-pharyngeal carcinoma. Part V: Discussion of long-term results of transoral laser microsurgery of hypopharyngeal carcinoma (see comments).] [German] Therapie des Hypopharynxkarzinoms. Teil V: Diskussion der Langzeitergebnisse der transoralen Lasermikrochirurgie beim Hypopharynx-karzinom." HNO. 1994; 42(3): 157-65.
Steiner W, Stenglein C, et al. "[Therapy of hypopharyngeal cancer. Part IV: Long-term results of transoral laser microsurgery of hypopharyngeal cancer (see comments)]. [German] Therapie des Hypopharynxkarzinoms. Teil IV: Langzeitergebnisse der transoralen Lasermikrochirurgie von Hypopharynx-karzinomen." HNO. 1994; 42(3): 147-56.
Steiner W. "[Therapy of hypopharyngeal cancer. Part III: The concept of minimally invasive therapy of cancers of the upper aerodigestive tract with special reference to hypopharyngeal cancer and trans-oral laser microsurgery (see comments)]. [Review] [0 refs] [German] Therapie des Hypopharynx-karzinoms. Teil III: Das Konzept der minimal invasiven Therapie von Karzinomen des oberen Aerodigestivtrakts unter besonderer Berucksichtigung des Hypopharynxkarzinoms und der transoralen Lasermikrochirurgie." HNO. 1994; 42(2): 104-12.
Kollisch M, Werner JA, et al. Functional results following partial supraglottic resection. Comparison of conventional surgery vs. transoral laser microsurgery. Advances in Oto Rhino Laryngology. 1995; 49: 237-40.
Rudert H. Technique and results of transoral laser surgery of supraglottic carcinomas. Advances in Oto Rhino Laryngology. 1995; 49: 227-30.
Werner JA, Lippert BM, et al. Laser delivery systems and laser instruments in otorhinolaryngology. [Review] [7 refs]. Advances in Oto Rhino Laryngology. 1995; 49: 27-30.
Ambrosch P, Freudenberg L, et al. "Selective neck dissection in the management of squamous cell carcinoma of the upper digestive tract." European Archives of Oto Rhino Laryngology. 1996; 253(6): 329-35.
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