Transoral Laser Microsurgery in Carcinomas of the Oral Cavity, Pharynx, and Larynx

Jochen A. Werner, MD, Anja A. Dünne, MD, Benedikt J. Folz, MD, Burkard M. Lippert, MD

Disclosures

Cancer Control. 2002;9(5) 

In This Article

Therapeutic Concept Beyond Laser Surgery

With regard to the prognosis of patients with head and neck cancers, therapy of the lymphatic system is of primary importance. Adequate treatment of the clinically node-negative neck (N0 neck) is the central point of controversy. At present, there is no uniformly accepted standard for the surgical treatment of the N0 neck in carcinomas of the head and neck. Recommendations range from no surgical intervention but with strict follow-up control, to a limited selective neck dissection as a solitary therapeutic measure even with histologic proof of metastases, or to a modified radical neck dissection in N0 necks and localized primary tumors.

Given the variability in treatment concepts among oncologic centers, certain guidelines need to be recognized. From our viewpoint, adopting a "wait-and-see" strategy rather than selective neck dissection may be justified in patients with a reliable compliance and in centers with broad expertise in ultrasonography imaging of the neck. With regard to surgical treatment, we anticipate that selective neck dissection will gain more acceptance in treating the N0 neck than modified radical neck dissection. The extent of selective neck dissection is determined by the localization of the tumor -- whether it is localized unilaterally or whether it reaches the midline or even expands over the midline. An exception to this strategy is T1 carcinoma of the vocal cord. A similar approach is currently supported in the literature for T2 glottic carcinoma.[16] However, advanced T2 glottic carcinoma, a low grade of differentiation of the primary tumor, as well as lymphangitis carcinomatosa, may warrant selective neck dissection in certain cases (levels II-III and possibly even level IV) even in these selected T2 glottic carcinomas cases. For all other tumor locations of the oral cavity,pharynx,and larynx,we currently recommend selective neck dissection. This usually includes levels I-III in carcinomas of the oral cavity and levels II-IV in oropharyngeal, laryngeal, and hypopharyngeal carcinomas.

Optimal therapy of the clinical N1 neck is also a controversial issue. In cases of glottic or hypopharyngeal carcinomas, consideration should be given to altering the modified radical neck dissection to ensure that lymph nodes of level I remain intact. However, in the clinical N2 neck, there is general consensus that a modified radical neck dissection should be performed.

In cases of a representative node dissection with a histologically proven N0 neck or single, isolated lymph node metastasis without extranodal spread or lymphangitis carcinomatosa, we do not include adjuvant radiochemotherapy in cases of total laser microsurgical resection of the primary.

Neck dissection is one technique that can be utilized within the context of the laser surgical primary resection or as a second-line approach. Steiner[16] often used the second-line approach with an interval of approximately 1 week between tumor resection and neck dissection. As a result of intensive investigations on the role of the sentinel node concept for squamous cell carcinoma of the upper aerodigestive tract,[20,21] we perform neck dissections as single-stage procedures parallel to laser surgical resections of the primary tumor in N0 neck cases because validity of the intraoperative proof of the initially draining lymph node correlates closely to the physiologic lymphatic drainage.

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