Cancers of the head and neck, including the most common form, squamous cell carcinoma, have long been managed by surgical resection. This may be performed as a sole modality of treatment for the cancer or combined with radiation and/or chemotherapy. The use of lasers in the management of lesions in the head and neck has been common place for many years. Lasers typically have been used to vaporized very superficial lesions or excise larger lesions. The primary limitation to the use of lasers for larger tumors has been the inability to adequately visualize the tumor through the limited access through the mouth and throat.
Standard surgical philosophy includes en bloc resection of a cancer with an adequate margin of normal tissue surrounding it to ensure complete excision and avoid spillage of tumor cells into the wound. This philosophy has been held to since the days of Halsted (1852 - 1922). The oral cavity, oropharynx, hypopharynx and larynx can be accessed through the mouth using various types of endoscopes. Understandably, however, the visualization through these scopes is fairly limited. Therefore, operations have been devised to gain access to this difficult area of the body by either dividing the jaw bone and interrupting the chewing and swallowing musculature or dividing this musculature deeper in the throat. These approaches have proven very effective to allow excellent visualization in tumor resection. However, there is a functional price to be paid in the form of scar tissue and prolonged rehabilitation.
While the use of lasers for treatment of cancer is not new, the techniques developed and advanced by professor Wolfgang Steiner at the University of Gottingen in Germany and others have allowed significant expansion of laser application. For nearly twenty years Dr. Steiner has been perfecting a technique and specialized instrumentation to allow removal of cancer from the mouth, throat and larynx through endoscopes in piecemeal fashion using the laser (endoscopic laser surgery or ELS). By intentionally removing the tumor one portion at a time, visualization is increasingly improved. In addition, the laser, which is attached to a microscope, allows significant magnification of the tissues at the time of their excision. The laser is used as a knife in this setting and as it cuts through tissues it can be readily determined under the microscope whether the tissues are normal or containing tumor. Thus, somewhat smaller margins of normal tissue can be taken with good assurance of clean resection, thus preserving tissue and function.
This less invasive approach to resecting the tumor avoids the need for extensive surgical exposure which dismantles important structures of the throat and the need for complicated reconstructive procedures. In most settings the wounds created by ELS tumor removal are allowed to heal over a period of weeks with impressive functional results. Functions such as swallow, breathing and voice can often be preserved where they might otherwise be lost or significantly impaired with more aggressive open techniques.
The concern about the utilization of such techniques expressed by most surgeons in the United States has been over the potential for recurrence of cancers due to the piecemeal removal of the cancer. Breaking a tumor up opens the possibility for tumor cells to escape from the main tumor mass and spread through lymphatic channels into surrounding tissues. Dr. Steiner has shown quite nicely that the laser seals lymphatics and his experience of thousands of cases using ELS has shown that his recurrence rates for comparable lesions is as good, if not better, than more aggressive open surgical procedures.
Excellent tumor control with very limited excision is achieved through the very meticulous and organized removal of the tumor in parts. As the tumor is removed it is mapped out and surgical margins directly inked by the surgeon at the time of removal to allow complete reconstruction of the tumor by the pathologist for analysis of all margins. This is facilitated by the magnification of the tissues at the time of the excision. If need be, the laser can be used to remove cartilage and the excision can be extended from the structures of the throat into the soft tissues of the neck to a limited degree.
Dr. Girod, from the University of Kansas Department of Otolaryngology Head and Neck Surgery, visited Dr. Steiner in February 2000 to study these techniques in depth. Dr. Girod was accompanied by colleagues from the Mayo Clinic, Baylor University, the University of Pittsburgh and several European institutions for a three-day intensive course reviewing Dr. Steiner's techniques, as well as to review the outcome of his several thousand procedures. Dr. Girod chose then to stay on for an additional two weeks for intense training by Dr. Steiner and his colleagues, as well as to observe the postoperative course and long-term functional outcome of patients undergoing this procedure.
The results observed in Gottingen, Germany were, in fact, very impressive. The technique, as described, was observed in the Operating Room and found to be highly successful. Observation of patients in the postoperative phase demonstrated significantly improved recovery times and functional outcomes in terms of speech and swallow. Remarkably, these operations were able to be performed even in the case of very large tumors without the requirement of the commonly used tracheostomy tube. The long term results were equally impressive.
A review of Dr. Steiner's data, while from one institution and one group of surgeons alone, was also very impressive. For Stage I, Stage II and many Stage III lesions long term cancer control rates were very comparable to, if not better, than much more aggressive open surgical approaches. In Germany, this technique is also used for large Stage III and Stage IV lesions. While the functional outcome was improved in these patients, long term survival was not as good as those using standard therapy in the United States. One difference being, however, that in the USA, for more advanced disease the combination of surgery and radiation therapy is used, where as radiation therapy is rarely used in Germany.
Based on this experience Dr. Girod and his colleagues have begun implementing this technique at the University of Kansas Medical Center in Kansas City. The necessary instrumentation was obtained and this technique has been in use since March 2000 with similarly favorable outcomes. Recent reports of results from the Mayo clinics at Jacksonville, Florida and Scottsdale, Arizona are also very favorable.
It is our impression that over the next five to ten years this technique will become dramatically more wide spread in acceptance from beyond a few dozen surgeons currently practicing these methods in the United States to being available at most major medical centers. While the operation is very tedious and time consuming, with appropriate patient selection, results can be much more rewarding than our experience with extensive open procedures. Not all tumors are currently amenable to this selective approach, but we believe this too will change with time as our experience grows.