LETTER TO THE EDITOR

The learning curve in the use of trans-oral laser microsurgeryfor cancer treatment

Patrick Bradley

Published online: 26 January 2013

� Springer-Verlag Berlin Heidelberg 2013

Dear Editor,

The authors from the University of Barcelona present their

experience of using trans-oral laser micro-surgery

(TOLMS) in the management of laryngeal and hypopha-

ryngeal cancers over a 14-year period and extrapolate from

analysis of the data [1], with surgeons graded by levels of

experience addressing early and locally advanced tumours,

as well as stage of disease and comment on patient out-

come using analysis of number of surgeries per patient, rate

of complications, rates of positive and negative tumour

margins, rate if tumour relapse, type of surgical salvage

procedure employed and disease-specific survival. The

difference between the mean of surgical interventions was

statistically significant, and the number of total laryngec-

tomy employed as a salvage procedure was lower in the

group of patients operated upon by more experienced

surgeons. Tumour-free margins and tumour relapse were

not influenced by experience. The number of overall

complications and the disease-specific survival rates was

significantly lower in the ‘‘expert’’ group. The authors do

agree that the learning curve of TOLMS for glottis,

supraglottic and hypopharyngeal lesions may be different,

and suggest that further analysis with larger numbers in

each sub-site is necessary. They also suggest that for

TOLMS ‘‘beginners’’ that early teaching, confidence and

analysis of competency should be gained with early

tumours. Based on their results it is suggested that expe-

rience in the use of TOLMS should be gained in a levelled

approach graduating from early tumours to intermediate

and then advanced T stage disease.

This paper is a first attempt to review a large series of

treated patients and analyse the involvement of surgeons of

differing experiences against a number of outcome mea-

sures. However, of the 5 surgeons work reported, all were

‘‘experienced’’ head and neck surgeons. The majority

(80 %) had more than 15 years of surgical experience

before commencing TOLMS, and the other surgeon was

less than 7 years experienced. Thus, the surgeons in this

report, while ‘‘new’’ to TOLMS had already got experience

of micro-laryngoscopy and bimanual surgical excisions,

identification of tumours and their margins prior to being

introduced to TOLMS. This may not be universally

equivalent when starting up a practice employing TOLMS

for the management of laryngeal and hypopharyngeal

cancers. The most important steps when considering

introducing ‘‘new technologies’’ into surgery is to ensure

that a ‘‘team approach’’ is agreed and developed—this

naturally in cancer surgery will involve the surgeon, the

anaesthetist and the histopathologist.

The introduction of such new clinical interventions and

surgical techniques may need to be approved by the local

hospital clinical governance board, and comply with cli-

nicians being able to demonstrate that they can meet

externally set of standards on appropriate training, as in the

UK NHS [2]. It is also important not to ignore that the data

need to be collected prospectively, documentation of

duration of surgery, hospital stay, complications, tumour

status of resection margins achieved, ability to salvage

close or positive margins, functional outcome—objective

and subjective evaluation of voice and swallowing out-

comes, as well as disease-specific survival. The ability

of residents (training grade) to achieve TOLMS exper-

tise is strongly influenced by the personal skills and

P. Bradley (&)

Department of Otorhinolaryngology - Head and Neck Surgery,

Nottingham University Hospitals, Queens Medical Centre

Campus, Nottingham, UK

e-mail: pjbradley@zoo.co.uk

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Eur Arch Otorhinolaryngol (2013) 270:1967–1968

DOI 10.1007/s00405-013-2357-8

resourcefulness of the individual surgeon [3]. Trans-oral

laser laryngeal surgical procedures are usually not stand-

ardised as open-neck techniques, in that the concept of

tailored resection is one of the most valuable advantages of

such an approach. The ability to minimise the rate of

unexpected positive superficial or deep margins is essential

to reduce the efficacy of the surgical treatment. These

issues should be considered in the teaching process of

TOLMS, which is difficult to learn and systematically

reproduce [3]. The close cooperation with an expert hist-

opathologist is of overwhelming importance, particularly

when dealing with the issue of close or positive margins.

The need for complete tumour removal at the first surgical

attempt is well recognised, and the ability to salvage

positive deep margins by repeating TOLMS may not be

successful and may require further treatment in the form of

open-neck surgery or the use of irradiation [3–5]. The

ability to achieve clear margin tumour resection is depen-

dent upon obtaining an adequate exposure of the tumour

either as a whole or by repositioning of the laryngoscope

when appropriate. When the lesion is small and can be

visualised within a single field of view then the specimen

should be resected in one piece, in larger tumours resection

can be performed piece-meal and the cut surfaces need to

orientated and scrutinised for the presence or absence of

cancer. Many authors report that both resection methods

were equally effective in achieving complete tumour

resection [1, 3, 4]. Some of these problems may be reduced

with adequate instrumentation and increasing experience.

The employment of frozen sections to confirm adequacy of

clear margins at the time of surgery is widely advocated [1,

3–7] but frozen sections do not always correlate with

permanent pathology [6]. The ability of pathologists to

reliably assess margins is related to the nature of the CO2

laser itself and includes tissue contraction and evaporation,

heat artefacts, or even small size of samples [8]. The reli-

ability of frozen section analysis depends on the surgeon’s

precision and pathologists’ experience [7]. When reporting

the surgery and results of outcome function, it is recom-

mended that the nomenclature proposed by the European

Laryngological Society should be used as this system

allows for consistent reporting and uniformity concerning

the extent and depth of resection [9, 10].

In the UK, the introduction of TOLMS was a slow and

gradual acceptance as an alternative surgical management

for selected head and neck cancers, and more for laryngeal

cancer, to encourage acceptance; a consensus meeting was

held amongst a group of ENT surgeons in 2008 [11]. The

terms of reference were to set areas where consensus would

be helpful and clinically beneficial. This meeting reported

the summaries of the four working groups on (1) standard

of care, (2) surgical procedures, (3) outcome measures and

(4) training and certification.

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