Do the characteristics of the tumor, the fact that it’s so infiltrating, bother you in terms of your ability to do the laser resection? he asked. In these cases, we basically depend on the appearance of the tumor under the microscope as we’re cutting it through and then we go into normal tissue. With margins like this, is that a problem, does that limit you?
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March 2009The more aggressive it is, Dr. Hoffman said, the more uncomfortable I am addressing it endoscopically with a laser and the more likely to convert to an open procedure.
Alternative Approaches
Dennis Kraus, MD, Director of the Speech, Hearing, and Rehabilitation Center at Memorial Sloan-Kettering Cancer Center in New York, proposed a different approach.
This is someone that I think I would be much more inclined to do an open partial laryngectomy on to begin with, he said. This man’s already failed radiation therapy. Your ability to obtain negative margins is going to be pretty limited. The inner surface of your margin is actually going to be the thyroid lamina and then looking at the endophytic nature of this tumor I’m concerned that you could have microscopically positive margins on the inner perichondrium.
Dr. Medina asked how to put some bulk in the defect after the surgery.
David Eisele, MD, Professor and Chairman of the Department of Otolaryngology-Head and Neck Surgery at the University of California, San Francisco, said, The symptoms are disproportionate to the lesion, which I think implies that there’s more disease than is clinically apparent here. I would do a vertical hemilaryngectomy on this patient and reconstruct with the strap muscles.
Nowadays, I think for medical-legal reasons it’s impossible to propose [chemotherapy] for these patients. Morbidity is too high.
-Daniel Brasnu, MD
Daniel Brasnu, MD, Chief of the Department of Otorhinolaryngology-Head and Neck Surgery at European Hospital Georges Pompidou in Paris, said his approach depends on the exposure level.
With this patient, if we can have very good exposure, I would propose endoscopic resection, he said. We still have the opportunity to do an open procedure if the laser option isn’t successful.
Second Case: Radiation or Resection?
In another case, a 67-year-old man reported that he had had hoarseness and throat congestion for five months. He had smoked three packs a day for 46 years but quit three years earlier.
An image showed a lesion that involved the anterior two-thirds of the vocal cord and extended up to the anterior commissure (Figure 2). There were about 9 to 10 millimeters of subglottic extension.