RESUMO
OBJECTIVE: Whenever a cortectomy is indicated, obviating preoperative biopsy and practicing a single-stage-laser-cordectomy (SSLC) may expedite treatment and preserve surgical planes. This may result in more superficial resections and improved vocal function. Yet, SSLC holds a risk for over-treating nonmalignant lesions. Our study aims to evaluate this risk. METHODS: A retrospective cohort of patients who underwent SSLC. Cordectomy types were compared with final pathology. Type-1 cordectomy was subcategorized into superficial-type-1 (superficial-lamina-propria preserved) and deep-type-1 (ligament exposed). Superficial-type-1 cordectomy was considered adequate for epithelial lesions not invading the basement membrane: nonmalignant, dysplasia, and carcinoma-in-situ (CIS). Deeper resections for these pathologies were considered inappropriately deep. All resections were considered appropriate for squamous cell carcinoma (SCC). RESULTS: Ninety-seven patients who underwent 139 SSLC were included. SCC was found in 30% (N = 42), CIS/severe-dysplasia in 15% (N = 21), mild/moderate-dysplasia in 23% (N = 32), nondysplastic lesions in 31% (N = 43), and lymphoma in 0.5% (N = 1). Superficial-type-1 cordectomy was performed in 64% (N = 89). Altogether, 15 lesions (11%) underwent inappropriately deep resections. Smoking history, current smoking status, prior glottic surgery, radiation or fungal infection, did not increase the rate of inappropriate deep resection. While the general rate of inappropriately deep resection is 11%, for deep-type-1 cordectomy or deeper the rate was 29.4%. The highest rate was associated with deep-type-1 cordectomy, reaching 52.9%. CONCLUSION: The general rate of inappropriately deep resection during a SSLC is low. However, when the depth of resection involves exposure of the vocal ligament or deeper, the rate increases. Hence, to avoid unnecessary morbidity, whenever a deep resection is considered, the authors recommend preceding a deeper resection with frozen section sampling.
RESUMO
BACKGROUND: Immunosuppression is strongly associated with an increased risk of developing cutaneous squamous cell carcinoma (cSCC). Studies on solid organ transplant recipients (SOTR) and chronic lymphocytic leukemia (CLL) patients have already demonstrated higher rates of aggressive cSCC tumors in these populations compared to immunocompetent controls. Studies on other immunosuppressed patient groups are scarce. This study was aimed at assessing the effects of different immunomodulating conditions on patients diagnosed with cSCC. We sought to compare the clinical features, treatments, and survival rates among the different study groups, as well as outcomes to those of immunocompetent controls with cSCC. METHODS: A retrospective analysis of 465 cSCC patients, both immunosuppressed (IS) and immunocompetent controls. Etiologies for immunosuppression included SOTR, CLL, chronic kidney disease (CKD), psoriasis, rheumatoid arthritis (RA) and systemic lupus erythematous (SLE). RESULTS: Compared to the control group, IS patients demonstrated several significant differences. These include higher rates of positive resection margins, higher recurrence rates, and multiple SCC tumors. Patients in the IS group, who were also given immunomodulating agents, demonstrated even lower survival rates. Cox regression analysis demonstrated statistically significant decreased overall survival (OS) rates for IS patients compared to the controls (OR = 1.9, p = 0.031). SOTR patients tend to have multiple cSCC tumors (35%), with the highest number of primary tumors compared to controls (2.54 tumors per patient on average, p < 0.001), but also compared to all other IS groups. The average SCC lesion size in the SOTR group was the smallest, measuring at 13.5 mm, compared to the control group and all other IS groups. Decreased survival rates were seen on Cox regression analysis compared to controls (HR = 2.4, p = 0.001), but also to all other IS groups. CLL patients also had the highest rates of positive margins compared to controls (36% vs. 9%, p < 0.01) and to all other IS groups. They were also most likely to get adjuvant or definitive oncological treatments, either radiotherapy or chemotherapy, compared to controls (36% vs. 15%, p = 0.02) and to other IS groups. Patients in the CKD group demonstrated the highest rates for multiple cSCC (OR = 4.7, p = 0.001) and the worst rates of survival on Cox regression analysis (HR = 3.2, p = 0.001). Both rheumatoid arthritis and psoriasis patients demonstrated the shortest disease-free survival rates (2.9y ± 1.1, 2.3y ± 0.7, respectively), compared to controls (4.1y ± 2.8) and to all other IS groups. CONCLUSIONS: Among cSCC patients, immunosuppression due to SOTR, CLL, CKD, RA, and psoriasis is associated with worse outcomes compared to controls and other IS groups. These patients should be regarded as high-risk for developing aggressive cSCC tumors. This study is the first to assess and compare cSCC outcomes among multiple IS patient groups.