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Impact of Margin Status on Laser Surgery for Early Glottic Cancer

Impact of Margin Status on Laser Surgery for Early Glottic Cancer I read with considerable interest the article titled “Laser Surgery for Early Glottic Cancer: Impact of Margin Status on Local Control and Organ Preservation” by Ansarin et al,1 which aimed to investigate the impact of margin status on local control and organ preservation in laser surgery for early glottic cancer. I would like to compliment the authors on their work, but I feel that some of the conclusions that they reached were not appropriately supported or explained by the statistical results. The authors analyzed 8-year disease-free survival according to margin status in 274 patients. Using multivariate analysis, patients with close (≤1 mm between margin and tumor) or positive margins who did not undergo a second resection and who did not receive radiotherapy (RT) had a greater risk of recurrence (hazard ratio, 2.53; 95% confidence interval, 0.97-6.59; P = .06) than patients with negative margins. However, the P value did not reach statistical significance (P < .05), and I could therefore not conclude that 1 mm is an adequate margin. Also, the category of 33 patients with close or positive margins who did not undergo another operation but who received RT also included 5 patients with negative margins. This classification is confusing and may complicate the survival results of patients with close margins. Furthermore, the object of the article was to discuss the impact of margin status on “local control.” However, the disease-free survival curve focused not only on local control but also on regional control. Finally, the comparison of organ preservation rate between the negative margin group and the close/positive margin group was not addressed in the article. Many case series suggest that transoral laser microsurgery and RT have comparable rates of local control for early glottic cancer.2 The benefit of choosing transoral laser surgery is to avoid irradiation complications. Therefore, the policy of adjuvant RT for T2-3 tumors in this study was quite complicated. For example, if adjuvant RT is always scheduled for patients with clinical T2 tumors, initial transoral laser surgery is unnecessary. Actually, in 54 patients with positive margins, 26 patients (48%) underwent a second operation and avoided further irradiation. Therefore, the suggestion that the adjuvant therapy for patients with close margins was only RT in this study seems unreasonable. In my opinion, some or most patients may benefit from a second wider resection, as reported in an article by Jäckel et al.3 In conclusion, the influence of margin status on local control, adjuvant treatment options, and organ preservation still remains unclear based on these results. Correspondence: Dr Wang, Department of Otolaryngology Head Neck Surgery, Taichung Veterans General Hospital, No. 160, Section 3, Taichung Harbor Road, Taichung City, Taiwan 40705 (entccwang@msn.com). Author Affiliation: Department of Otolaryngology Head Neck Surgery, Taichung Veterans General Hospital, Taichung City, Taiwan. References 1. Ansarin MSantoro LCattaneo A et al. Laser surgery for early glottic cancer: impact of margin status on local control and organ preservation. Arch Otolaryngol Head Neck Surg 2009;135 (4) 385- 390PubMedGoogle ScholarCrossref 2. Agrawal NHa PK Management of early-stage laryngeal cancer. Otolaryngol Clin North Am 2008;41 (4) 757- 769, vi-viiPubMedGoogle ScholarCrossref 3. Jäckel MCAmbrosch PMartin ASteiner W Impact of re-resection for inadequate margins on the prognosis of upper aerodigestive tract cancer treated by laser microsurgery. Laryngoscope 2007;117 (2) 350- 356PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Impact of Margin Status on Laser Surgery for Early Glottic Cancer

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Publisher
American Medical Association
Copyright
Copyright © 2010 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archoto.2009.221
Publisher site
See Article on Publisher Site

Abstract

I read with considerable interest the article titled “Laser Surgery for Early Glottic Cancer: Impact of Margin Status on Local Control and Organ Preservation” by Ansarin et al,1 which aimed to investigate the impact of margin status on local control and organ preservation in laser surgery for early glottic cancer. I would like to compliment the authors on their work, but I feel that some of the conclusions that they reached were not appropriately supported or explained by the statistical results. The authors analyzed 8-year disease-free survival according to margin status in 274 patients. Using multivariate analysis, patients with close (≤1 mm between margin and tumor) or positive margins who did not undergo a second resection and who did not receive radiotherapy (RT) had a greater risk of recurrence (hazard ratio, 2.53; 95% confidence interval, 0.97-6.59; P = .06) than patients with negative margins. However, the P value did not reach statistical significance (P < .05), and I could therefore not conclude that 1 mm is an adequate margin. Also, the category of 33 patients with close or positive margins who did not undergo another operation but who received RT also included 5 patients with negative margins. This classification is confusing and may complicate the survival results of patients with close margins. Furthermore, the object of the article was to discuss the impact of margin status on “local control.” However, the disease-free survival curve focused not only on local control but also on regional control. Finally, the comparison of organ preservation rate between the negative margin group and the close/positive margin group was not addressed in the article. Many case series suggest that transoral laser microsurgery and RT have comparable rates of local control for early glottic cancer.2 The benefit of choosing transoral laser surgery is to avoid irradiation complications. Therefore, the policy of adjuvant RT for T2-3 tumors in this study was quite complicated. For example, if adjuvant RT is always scheduled for patients with clinical T2 tumors, initial transoral laser surgery is unnecessary. Actually, in 54 patients with positive margins, 26 patients (48%) underwent a second operation and avoided further irradiation. Therefore, the suggestion that the adjuvant therapy for patients with close margins was only RT in this study seems unreasonable. In my opinion, some or most patients may benefit from a second wider resection, as reported in an article by Jäckel et al.3 In conclusion, the influence of margin status on local control, adjuvant treatment options, and organ preservation still remains unclear based on these results. Correspondence: Dr Wang, Department of Otolaryngology Head Neck Surgery, Taichung Veterans General Hospital, No. 160, Section 3, Taichung Harbor Road, Taichung City, Taiwan 40705 (entccwang@msn.com). Author Affiliation: Department of Otolaryngology Head Neck Surgery, Taichung Veterans General Hospital, Taichung City, Taiwan. References 1. Ansarin MSantoro LCattaneo A et al. Laser surgery for early glottic cancer: impact of margin status on local control and organ preservation. Arch Otolaryngol Head Neck Surg 2009;135 (4) 385- 390PubMedGoogle ScholarCrossref 2. Agrawal NHa PK Management of early-stage laryngeal cancer. Otolaryngol Clin North Am 2008;41 (4) 757- 769, vi-viiPubMedGoogle ScholarCrossref 3. Jäckel MCAmbrosch PMartin ASteiner W Impact of re-resection for inadequate margins on the prognosis of upper aerodigestive tract cancer treated by laser microsurgery. Laryngoscope 2007;117 (2) 350- 356PubMedGoogle ScholarCrossref

Journal

Archives of Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: Feb 15, 2010

References