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. 2014 Jun;34(3):174-83.

Direct autofluorescence during CO2 laser surgery of the larynx: can it really help the surgeon?

G Succo  1 , P Garofalo  1 , M Fantini  1 , V Monticone  1 , G C Abbona  2 , E Crosetti  3
Affiliations

Direct autofluorescence during CO2 laser surgery of the larynx: can it really help the surgeon?

G Succo et al. Acta Otorhinolaryngol Ital. 2014 Jun.

Abstract
in English, Italian

Herein we assessed the impact of direct autofluorescence during intraoperative work-up on obtaining superficial free resection margins, identifying new areas of malignant transformation and altering disease-free survival and local control at 3 years in patients submitted to transoral laser surgery (TLS) for early glottic cancer. Prospective cohort evaluation was carried out on the diagnostic accuracy of the superficial extent and TNM staging in 73 patients with glottic carcinoma undergoing transoral CO2 laser surgery. The use of direct autofluorescence was associated with superficial disease-free margins in 97.2% of cases, and with superficial close margins in 2.8%. The improvement in diagnostic accuracy was 16.4%; in 8.2% of cases, there was upstaging of the TNM classification (in one case, a second neoplastic area in a different laryngeal site was observed and considered to be a second endolaryngeal primary). The sensitivity of direct autofluorescence was 96.5% with a specificity of 98.5%. Overall, 3-year disease-specific survival and local control with laser alone were, respectively: T1a (97.5%, 100%), T1b (86.7%, 86.7%), T2 (88.9%, 88.9%). This study demonstrates that direct autofluorescence can help to identify positive superficial margins, and has a favourable impact on disease-specific survival and local control at 3 years.

Obiettivo di questo studio è stato valutare l'impatto dell'autofluorescenza diretta durante il work-up intraoperatorio nell'ottenere margini di resezione superficiale indenni, nell'individuare nuove aree di trasformazione maligna e nel migliorare a 3 anni la sopravvivenza libera da malattia/controllo locale nei pazienti sottoposti a laserchirurgia transorale (TLS) per cancro della glottide in fase iniziale. (Disegno dello studio: studio di coorte prospettico). Una valutazione prospettica sull'accuratezza diagnostica dell'estensione superficiale e sulla stadiazione TNM è stata condotta in 73 pazienti con carcinoma della glottide sottoposti a laserchirurgia transorale. L'utilizzo dell'autofluorescenza diretta ha determinato margini superficiali liberi da malattia nel 97,2 % dei casi e margini superficiali esigui nel 2,8 %. Un miglioramento nell'accuratezza diagnostica si è verificato nel 16,4 % mentre nell'8,2 % dei casi si è assistito ad un up-staging della classificazione TNM (in un caso un'area neoplastica in una sede laringea distinta è stata considerata un secondo tumore endolaringeo primitivo). La sensibilità dell'autofluorescenza diretta è stata del 96,5%, la specificità del 98,5%. Nel complesso la sopravvivenza malattia-specifica ed il controllo locale con laser a 3 anni sono stati rispettivamente: T1a (97,5 % ,100 %), T1b (86,7%, 86,7%), T2 (88,9%, 88,9%). Concludendo questo studio dimostra che l'autofluorescenza diretta può aiutare il chirurgo nell'identificare i margini superficiali positivi e risulta associata ad un impatto favorevole sulla sopravvivenza malattia-specifica e sul controllo locale a 3 anni.

Keywords: Autofluorescence; Endoscopic surgery; Glottic tumour; Laryngeal cancer; Resection margins; Transoral laser surgery.

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Figures

Fig. 1.
Fig. 1.
Stepwise protocol used for intraoperative work-up. A: during direct microlaryngoscopy, initial assessment in white light of a suspected left vocal cord SCC staged cT1a; B: the area of excision is marked with several laser spots, maintaining an apparent margin of healthy tissue of approximately 2 mm compared to the visible limits of the suspected neoplastic lesion; C: assessment of field using direct autofluorescence showing an area of surgical excision insufficient compared to that found by autofluorescence in the dark [the histological examination on the surgical specimen and biopsy on the contralateral vocal cord found an invasive SCC in both the site of the clinically visible tumour (red circle) and in the contralateral vocal cord (yellow circle) → upstaging from glottic T1a to T1b].
Fig. 1.
Fig. 1.
Stepwise protocol used for intraoperative work-up. A: during direct microlaryngoscopy, initial assessment in white light of a suspected left vocal cord SCC staged cT1a; B: the area of excision is marked with several laser spots, maintaining an apparent margin of healthy tissue of approximately 2 mm compared to the visible limits of the suspected neoplastic lesion; C: assessment of field using direct autofluorescence showing an area of surgical excision insufficient compared to that found by autofluorescence in the dark [the histological examination on the surgical specimen and biopsy on the contralateral vocal cord found an invasive SCC in both the site of the clinically visible tumour (red circle) and in the contralateral vocal cord (yellow circle) → upstaging from glottic T1a to T1b].
Fig. 1.
Fig. 1.
Stepwise protocol used for intraoperative work-up. A: during direct microlaryngoscopy, initial assessment in white light of a suspected left vocal cord SCC staged cT1a; B: the area of excision is marked with several laser spots, maintaining an apparent margin of healthy tissue of approximately 2 mm compared to the visible limits of the suspected neoplastic lesion; C: assessment of field using direct autofluorescence showing an area of surgical excision insufficient compared to that found by autofluorescence in the dark [the histological examination on the surgical specimen and biopsy on the contralateral vocal cord found an invasive SCC in both the site of the clinically visible tumour (red circle) and in the contralateral vocal cord (yellow circle) → upstaging from glottic T1a to T1b].
Fig. 2.
Fig. 2.
A: during direct microlaryngoscopy, initial assessment in white light of a suspected right vocal cord SCC staged cT2; B: assessment of field using direct autofluorescence showing the safe margin between the inferior extremity of vestibulectomy (yellow circle) and the lateral extremity of the area previously marked for excision (histological examination on the surgical specimen found a free margin = 2 mm).
Fig. 2.
Fig. 2.
A: during direct microlaryngoscopy, initial assessment in white light of a suspected right vocal cord SCC staged cT2; B: assessment of field using direct autofluorescence showing the safe margin between the inferior extremity of vestibulectomy (yellow circle) and the lateral extremity of the area previously marked for excision (histological examination on the surgical specimen found a free margin = 2 mm).
Fig. 3.
Fig. 3.
Study design showing results of histological evaluation and endoscopic follow-up in 73 patients. Each evaluation is described with respect to direct autofluorescence status [positive to autofluorescence (PAF), negative to autofluorescence (NAF), autofluorescence not applicable (ANA)], location of examined areas [tumour, white light endoscopy negative area (WLENA), definitive superficial margins, deep margins], status to endoscopic follow-up Negative (N), superficial recurrence on surgical boundaries (SRSB) deep submucosal recurrence in surgical field (DSRSF), recurrence in separate laryngeal site (RSLS)].
Fig. 4.
Fig. 4.
A: during direct microlaryngoscopy, initial assessment in white light of a red hyperplastic lesion at the anterior part of the vocal cord; B: assessment of field using direct autofluorescence showing an area positive to direct autofluorescence encompassing the anterior commissure (histological examination on the surgical specimen found a CIS both at the site of a clinically more visible red lesion (red circle) and in the contralateral vocal cord (yellow circle).
Fig. 4.
Fig. 4.
A: during direct microlaryngoscopy, initial assessment in white light of a red hyperplastic lesion at the anterior part of the vocal cord; B: assessment of field using direct autofluorescence showing an area positive to direct autofluorescence encompassing the anterior commissure (histological examination on the surgical specimen found a CIS both at the site of a clinically more visible red lesion (red circle) and in the contralateral vocal cord (yellow circle).
Fig. 5.
Fig. 5.
A: during direct microlaryngoscopy, initial assessment of the left vocal cord in white light; B: assessment of field using direct autofluorescence showing a bright white hyperkeratotic lesion with slight positivity to direct autofluorescence on the mucosal margins of the lesion (yellow circles) (histological examination on the surgical specimen found a SCC in the areas marked with the yellow circles).
Fig. 5.
Fig. 5.
A: during direct microlaryngoscopy, initial assessment of the left vocal cord in white light; B: assessment of field using direct autofluorescence showing a bright white hyperkeratotic lesion with slight positivity to direct autofluorescence on the mucosal margins of the lesion (yellow circles) (histological examination on the surgical specimen found a SCC in the areas marked with the yellow circles).
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