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Prospective randomized blinded study. Patients with glottic cancer undergoing laser resection were randomized to margin excision by either steel instruments or CO2 laser. Margins were analyzed for size, interpretability and degree of artifact by a pathologist who was blinded to technique.
Removal of adequate glottic resection margins after TLM can be technically challenging, and margins must be taken precisely to balance the need for sufficient tissue to analyze while maximizing the preservation of normal tissue. Steel instruments have traditionally been used to take margins due to concerns regarding interpretation of margins with laser artifact. Unfortunately, margin resection with steel instruments does not have the hemostatic benefits of CO2 or the stabilized cutting of the micromanipulator. As the pulsed setting of the laser significantly reduces the amount of thermal damage and artifact, margins at our center have routinely been taken by ultrapulsed laser to achieve these benefits.
The main objective of this study is to compare the degree of artifact and the rate of uninterpretability for glottic cancer margin specimens when excised using either CO2 laser on ultrapulse mode or steel phonomicrosurgical instruments. Our hypothesis is that margin excision using CO2 laser on ultrapulse mode can be as interpretable as using steel instruments.
Patients were placed under general anaesthesia and intubated using laser resistant endotracheal tube. Laser safety measures were implemented to minimize the risk of complications from the laser surgery. Patients were placed in suspension laryngoscopy and an operative microscope with CO2 laser micromanipulator was used for glottic cancer excision. Carbon dioxide laser settings were 2-4 watts in ultrapulse mode. Depending on size, the tumours were removed either en bloc or via a tumour splitting technique. After primary tumor excision, margins were taken from the surgical site using either steel phonomicrosurgical instruments or CO2 laser at 2 watts based on our randomization list. The same phonomicrosurgical instruments were used to retract specimens for both cutting techniques. The locations of margins were diagrammed on the laryngeal template to assist the pathologist in their orientation.
The study cohort was composed of 45 patients with 23 randomized to have margins taken by CO2 laser and 22 randomized to have margins taken with steel phonomicrosurgical instruments. See Table 2 for patient demographics. Overall, there were 226 margins taken, 115 margins taken with CO2 laser and 111 taken with steel phonomicrosurgical instruments (Table 3).
Accurate assessment of surgical margins is a key factor in proper management and the predictive risk of local recurrence. The present study demonstrates that both steel instruments and CO2 laser cause a significant degree of artifact that can interfere with accurate margin assessment in TLM for early glottic cancer. The use of laser to harvest margins in our study was not associated with increased crude rates of uninterpretability for malignancy but was associated with increasing artifact affecting the ability of the pathologist to assess for dysplasia.
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