Margins in Laryngeal Squamous Cell Carcinoma Treated with Transoral Laser Microsurgery: A National Database Study

Abstract

Objectives To determine national positive margin rates in transoral laser microsurgery, to compare patients with positive and negative margins, and to identify factors associated with positive margins. Study Design Retrospective review of the National Cancer Database. Setting Population based. Subjects/Methods Patients included those with TIS-T3 laryngeal squamous cell carcinoma (2004-2014). Univariable and multivariable logistic regression were used to identify predictors. Results A total of 1959 patients met inclusion criteria. The national positive margin rate was 22.3%. Sixty-five percent of patients had T1 disease; 94.3% were N-negative; and 74.0% had glottic tumors. Fifty-eight percent of patients were treated at academic centers, and 60.6% were treated at facilities performing <2 cases per year. On multivariable analysis, factors associated with margin status included facility volume (odds ratio [95% CI]; in cases per year: 0.93 [0.89-0.97], P = .001), academic status (vs nonacademic; academic: 0.70 [0.54-0.90], P = .008), T-stage (vs T1; T2: 2.74 [2.05-3.65], T3: 5.53 [3.55-8.63], TIS: 0.59 [0.38-0.92], P < .001), and N-stage (vs N0; N1: 3.42 [1.79-6.54], N2: 2.01 [1.09-3.69], P < .001). Tumor subsite was not associated with margin status. Conclusion The national positive margin rate for laryngeal laser surgery is 22%, which is concerning given the equivalent survival benefit offered by surgery and primary radiation and the increased likelihood of bimodal therapy in the situation of positive margins. Cases treated at nonacademic centers and those with lower caseloads had a higher likelihood of positive margins. There was a linear association between T-stage and likelihood of positive margins, with T3 tumors being 5 times as likely as T1 to yield positive margins. This study highlights the importance of proper patient selection for transoral laser microsurgery resections.

T1 glottic laryngeal cancer: the role of routine follow-up visits in detecting local recurrence

“…The National Cancer Database study from the USA assessed positive margin rates in trans-oral laser microsurgery of LSCC. Cases treated at non-academic centers and those with lower caseloads had a higher likelihood of positive margins [ 21 ]. Silverman et al showed that postoperative radiotherapy of T1-T2 LSCC was significantly more common in low-volume centers [ 22 ].…”

Could Primary Chemoradiotherapy in T2 Glottic Cancers Yield Results Comparable to Primary Radiotherapy in T1? Considerations from 531 German Early Stage Patients

“…Thus, intensive individual counseling is fundamental. Two prerequisites for safe endoscopic resection are optimal anatomical exposure of the tumor and sufficient expertise and caseload of the institution and the individual surgeon [ 81 ]. There should be no doubt that R0 resection is safely achievable.…”

Chemoradiotherapy but Not Radiotherapy Alone for Larynx Preservation in T3. Considerations from a German Observational Cohort Study

“…This notion is consistent with the finding in our observational cohort study: the adjusted HR was 3.5 (95%-CI: 2.2–5.7) for advanced N stage [ 30 ]. In many other studies, N stage, especially advanced N stage N2–3, was reported as an independent negative prognostic marker [ 26 , 27 , 31 , 32 ].…”

“…For surgery, laser surgery is an option only in selected cases of T3 laryngeal cancer [ 55 , 56 ]. If it is chosen, the result is largely dependent on the expertise of the surgeon and the caseload of the facility [ 31 ]. The most effective and comparable surgery for the comparison of efficacy between surgical and nonsurgical treatment in T3 laryngeal cancers is total laryngectomy (TL).…”