嗓音显微手术治疗早期声门癌的远期疗效观察

Long-term effect of phonomicrosurgery on early glottic cancer

目的观察应用嗓音显微手术治疗早期声门癌的远期疗效.方法1989-1997年采用嗓音显微外科技术对44例声带早期癌（T1a）进行了手术治疗.声带早期癌按病变的侵袭深度分为：原位癌（5例）、低侵袭癌（33例）和侵袭癌（6例）.原位癌和低侵袭癌采用微瓣切除技术;对侵袭癌则采取激光切除声带,切缘经过微波或激光处理的方法.每例患者均进行术前、术中和术后录像,术后常规病理送检,并进行长期随访.随访最长时间为11年,最短时间5年.结果应用微瓣切除方法的38例原位癌和低侵袭癌中有6例在手术后随访的2～3年内发现局部复发,局部复发率为15.8%.6例复发患者再次行微瓣切除,其中1例在10年内经历3次微瓣切除手术.1例失随访后1年再次因肿瘤复发就诊,后改喉全切除手术.微瓣切除术病例失访4例,其余随访5年以上均存活,5年生存率为89.5%（失访以死亡计）.应用声带切除术的6例早期侵袭癌中2例于术后2个月发现肿瘤复发而行喉切除术,1例失随访后3年复发改喉全切除术,1例梭型细胞癌术后采用局部放射治疗.声带切除术局部复发率为4/6;3例在3年内死亡,1例3年后失访,2例存活5年以上.结论对病变局限的早期癌,嗓音显微手术不仅能有效地治愈疾病,同时能保护和维持正常的发声功能.对于病变局限在黏膜表面的声带早期癌,嗓音显微手术的微瓣技术不仅是有效的微创治疗措施,同时微瓣切除的病变标本经连续切片的病理诊断也成为了早期声带癌诊断及鉴别诊断的“金标准”.

Objective To observe the end results related to the early glottic cancer by means of phonomicrosurgery. Methods During 1989--1997, 44 cases of the early glottic cancer underwent phonomicrosurgery. The early glottic cancer were classified into three types according to depth of penetration of the vocal cord lesions, such as carcinoma in situ （ 5 cases）, microinvasive carcinoma （ 33 cases） and invasive carcinoma（6 cases）. Microflap resection techniques were used in both of the carcinoma in situ（CIS） and the microinvasive carcinoma （ CA）, while the laser cordectomy was used in patients of invasive glottic cancer with surgical margins dissected by the carbon dioxide laser. Submucosal vocal cord infusion is employed to indentify the two different choices. 1/10 000 epinephrine sterile saline was injected into superficial lamina propria, if the lesion was swollen as well as the epithelium, it suggested the vocal cord lesions were above the superficial lamina propria, microflap excision could be selected. Otherwise ＂doughnut effect＂ phenomena was observed that demonstrated distension of the SLP peripheral to the central attachment of the neoplastic lesion to the MLP or DLP, then laser cordectomy was choosed. Each patient was recorded pre and post-operation with histopathological analysis. A long term follow-up was established at 2-month to 1 year interval. The longest had been 11-year, while the shortest 5-year. Results Six （15. 8% ） of 38 lesions treated for CIS and CA with microflap excision were recurred locally within 2 to 3-year. All of them were performed with microflap resection. One of 6 cases underwent 3 times of microflap operation within 10-year, one patient developed invasive cancer ,therefore transcervical laryngectomy was used. The 5-year survival rate was 89. 5%. Two of 6（33.3% ） invasive carcinoma with cordectomy were recurred parcel two months postoperatively, they were submitted to traditional laryngectomy. One lost to follow-up was found recrudesce three years after operation, he received open transcervical laryngectomy. One patient with fusiform cell cancer employed local radiation therapy. The 5-year survival rate was 66. 7% . Conclusions On the management of early glottic cancer, Phonomicrosurgery not only eliminates the diseases , but also preserves ＂normal＂ voice. Microflap excision is an effective microtrauma therapeutic technique, and the resected specimen is also a ＂golden criteron＂ for the diagnosis and differential diagnosis related to early glottic carcinoma.