The Limitations of Trans-Oral Endoscopic Laser Resection in the Management of Laryngeal Cancer with Anterior Commissure Involvement: Retrospective, Cross sectional studies and review of clinical experience

The Limitations of Trans-Oral Endoscopic Laser Resection in the Management of Laryngeal Cancer with Anterior Commissure Involvement: Retrospective, Cross sectional studies and review of clinical experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Limitations of Trans-Oral Endoscopic Laser Resection in the Management of Laryngeal Cancer with Anterior Commissure Involvement: Retrospective, Cross sectional studies and review of clinical experience Mohamed Sadek Rifai, Magdy M. Mansy, Muhammed AbdAllateef, Mena Esmat Abdelmalek This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8402375/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Aim of the work: This study assesses the limitations of transoral laser microsurgery (TLM) for early-stage laryngeal cancer involving the anterior commissure (AC), specifically examining the relationship between recurrence and thyroid cartilage invasion. Patients and methods: A retrospective review of 32 T1-T2 glottic carcinoma patients treated with TLM between May 2023 and April 2025 analysed recurrence and progression over 3–24 months. Concurrently, a cross-sectional analysis of five laryngectomy specimens from recurrent cases evaluated AC involvement and thyroid cartilage invasion. Results: The cohort comprised 19 T1 and 13 T2 tumors. Recurrence occurred in 22 patients (54%), with 14 (63.6%) recurring at the same stage and 8 (36.4%) progressing. Salvage treatment consisted of 15 conservative surgeries (68.2%) and 7 total laryngectomies (31.8%). Histological analysis of all five laryngectomy specimens revealed tumor involvement of the cartilage. Conclusions: AC involvement significantly impacts prognosis in early-stage laryngeal cancer. Given the increased recurrence risk after TLM or DRT associated with AC, vocal cord, supraglottic, or subglottic involvement, and the potential need for total laryngectomy, conservative surgical approaches should be considered cautiously in these cases. Trans oral endoscopic laser resection (TLS) anterior commissure (AC) Radiotherapy (RT) Conservative laryngeal surgery (CLS) Total laryngectomy (TL) Neck dissection (ND) Squamous cell carcinoma (SCC) Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction (TLS) developed as a larynx-preserving treatment for early-stage (T1s, T1a) laryngeal cancer localised to the mid-vocal cord without (AC) involvement. 1 – 4 Its use expanded to T1b and T2 lesions 5 and 6 , including those requiring extended cordectomies with or without arytenoid cartilage resection, and occasionally involving perichondrium or the cricothyroid membrane 7 . Laser debulking, then external beam radiation, was also used 8 , 9 ad 10 . The term "Laser irradiation" was surprisingly quoted 9 . However, high recurrence rates after TLS, especially in T1b and T2 glottic cancers involving the (AC), led some to favour external conservation approaches for T1b, T2 11 , and early T3 lesions, cautioning against TLS for T3 tumors 12 , 13 , and 14 . Conversely, many studies reported using (TLS) 15 – 16 and/or (RT) 17 – 18 for advanced (T2-T4) glottic and selected supra-glottic carcinomas, often combined with neck dissection and/or (RT) 15 – 19 and 20– 21 , sometimes overlooking the anterior commissure and sub-glottic region. Surgical lasers demonstrated promising outcomes in the management of laryngeal malignancies, including advanced stage III and IV tumors, as evidenced by a substantial body of literature. These publications frequently introduce novel terminologies, including local control, disease-free survival, disease-specific survival, and …, potentially overshadowing the conventional five-year cure rate. The increasing complexity of statistical methodologies employed to analyse treatment outcomes appears driven by a desire to refine results and emphasize the perceived benefits of surgical laser interventions. Modern statistics often obscure rather than clarify the real impact of surgical lasers, contradicting clinical experience and research that dispute claims of impressive results. 22 – 23 . Kasr Al Aini Hospital's Otolaryngology Department, a tertiary referral centre in Egypt, manages approximately 150 outpatient consultations and performs 12 daily surgeries (including three major cases) six days a week. It also provides 24/7 emergency services daily. A retrospective review of hospital records from May 2023 to April 2025 identified only 32 patients with recurrent T1/T2 laryngeal carcinoma treated with TLS during those two years. Materials and Methods This retrospective analysis examined 32 patients diagnosed with T1/T2 laryngeal squamous cell carcinoma treated with TLS between May 2023 and April 2025. 19 patients with T1N0M0 tumours and 13 patients with T2N0M0 tumours were included. Within the T1N0M0 cohort, 12 lesions abutted the (AC), and 8 patients received adjuvant (RT). In the T2N0M0 group, nine cases exhibited clinical AC involvement, and all 13 patients received post-TLS RT. Of these 32 patients, 22 experienced recurrence within 3–24 months.All underwent diagnostic staging. Subsequent surgical management, based on the current stage, consisted of either conservative laryngeal surgery (CLS) or total laryngectomy (TL), with or without neck dissection (ND). Patients with T3 or T4 lesions received (DXT) if they had not previously received a full dose after (TLS). Minimum follow-up was 2 years. A Cross-sectional study of five random laryngectomy specimens (2 CLS, 3 TL), was performed to determine the relationship between recurrent tumour and cartilage in the (AC) region. Ethical approval: This retrospective analysis was conducted after obtaining approval from the Research Ethics Committee (Approval No: N-293-2025). The requirement for informed consent was waived due to the retrospective nature of the study. Results A retrospective review of hospital records identified 32 patients diagnosed with T1/T2 laryngeal carcinoma treated with TLS between May 2023 and April 2025. Out of 19 patients with T1N0M0 glottic lesions, 13 patients (68.4%) experienced a recurrence. Among these, nine patients still had T1N0M0 lesions that involved the (AC) and underwent (CLS). Lesions were more aggressive in the remaining four patients. One had T3N0M0 lesions and underwent (CLS). The remaining three patients had T4N1M0 tumors and underwent (TL) along with (ND). Recurrence occurred in 69.2% (9/13) of patients with T2N0M0 glottic lesions. Of these, five T2N0M0 patients with (AC) involvement underwent (CLS). Three T3N2M0 and one T4N2M0 patient underwent (TL) and (ND). Of 32 patients, nineteen presented with T1 disease and thirteen with T2. Following (TLS) failure, 22 patients (54%) experienced recurrence within 3-24 months. Of these, 14 (63.6%) recurred at the same initial stage, while eight (36.6%) progressed to a more advanced stage. There were fifteen patients (68.18%) who had (CLS), and seven (31.8%) had (TL). Cartilage invasion manifested through three distinct mechanisms. These included direct invasion without a clear tissue plane of demarcation (Figure 3), abutment exhibiting an expanding margin lacking a defined barrier (Figure 4), and infiltration via satellite foci of squamous cell carcinoma (SCC) (Figure 5). Discussion While initially considered effective for early laryngeal cancer, TLS has significant limitations. High recurrence rates, particularly in T1b and T2 glottic carcinomas 24 and the risk of disease progression, as demonstrated in this study, suggest TLS may not be the best option for many patients. Laser technology, while sometimes presented as revolutionary, functions primarily as a precise surgical instrument with limited impact on overall homeostasis 25 . The enthusiasm surrounding lasers has led to the introduction of terms such as “laser debulking” 8 , “laser irradiation” 10 , and “thermal sterilisation”, potentially overstating their unique capabilities. Residual carcinoma in resection specimens correlated with increased loco-regional failure. The conventional 5 mm margin for laryngeal cancer resection is increasingly being challenged 26-27 . Management of early laryngeal cancer requires careful assessment of (AC) involvement, a key prognostic factor. While the (AC) is involved in about 20% of early glottic squamous cell carcinomas, isolated tumors there are uncommon (1% of all glottic cancers) 28 . Tumor spread can involve the contralateral vocal cord, thyroid cartilage, and pre-epiglottic space, influencing treatment and prognosis. Under staging is frequent (24%) 29 , potentially leading to T1 lesions being reclassified as T4 based on deep cartilage invasion. Sub-glottic extension also poses a challenge, as sub-mucosal spread can occur through the cricothyroid membrane. This study emphasises (AC)’s critical role in treatment planning for malignant laryngeal tumors. A retrospective review of 32 patients (19 T1, 13 T2) treated with TLS revealed a 54% recurrence rate (22 patients) within 3-24 months, with clinical AC involvement observed in 63.6% (14) of initial lesions, further underscoring the AC's significance. Underestimating tumour extent and inadequately addressing cartilage invasion increases recurrence risk due to incomplete resection. While adjuvant (RT) is recommended to improve local control 8, 10, 20 and 30 , it has inherent risks and may not fully compensate for the limitations of (TLS) 31 . Patients often require total laryngectomy following unsuccessful attempts to preserve the larynx through partial resection or (RT). Salvage surgery in these instances carries a significant risk of operative and postoperative complications 32 . Preoperative tracheostomy in patients with laryngeal carcinoma has been associated with an increased risk of stomal recurrence, potentially due to implantation of tumor cells around the tracheostomy 33 . The presence of tumor in the resected margins correlates with a higher incidence of local recurrence and a less favourable prognosis 34 . Several factors contribute to positive margins in partial laryngeal surgery. The nature of the surgery often necessitates resection close to the tumor. Furthermore, anatomical considerations, such as the reluctance to sacrifice the (AC) and opposite vocal fold, can contribute to involved margins at these sites 35 . Conclusion Meticulous patient selection and precise tumor staging are paramount for successful (TLS). In advanced-stage lesions, open surgical techniques may be more appropriate. Surgical re-excision to achieve histologically negative margins is mandatory. This is challenging with (TLS), particularly for large tumors (T2-T4) or those involving the (AC). Recurrence following (TLS) or definitive (RT) may necessitate (TL), resulting in loss of laryngeal function. Specifically, involvement of the (AC), as well as disease extension to other vocal cord regions, the supra-glottis, or the sub glottis, significantly elevates the risk of recurrence after (TLS) and (RT), thus warranting consideration of more conservative surgical strategies in these clinical scenarios. Optimal therapeutic selection necessitates collaborative decision-making between patients and surgeons. While respecting patient autonomy is paramount, the pursuit of trans-oral laser microsurgery (TLM) or radiotherapy (RT) exclusively to circumvent laryngectomy is professionally and ethically questionable without a rigorous evaluation of oncological principles and associated risks. Surgeons bear the responsibility of providing patients with a comprehensive explanation of all potential risks. No statement captures this dilemma more wisely than this quotation: "Radiotherapy is unlikely to cure cancer due to its limitations, evidenced by static survival rates over the past two decades. Poor outcomes in advanced head and neck cancer care may obscure underlying mismanagement, due to the disease's natural progression, potentially misleading general practitioners and even other surgeons. 36 Declarations Funding: No funding was received for this study. Author Contribution 1. Mohamed Sadek Rifai: main surgeon 2. Magdy M. Mansy: pathology study of samples3. Muhammed Abd Al-lateef Muhammed Abd Al-lateef & 4. Mena Esmat Abdelmalek : reviewed the manuscript References Eckel HE (1993) Topographical and clinico-oncologic analysis of locoregional recurrence after transoral laser surgery for laryngeal cancer. Laryngorhinootologie 72:8 406 – 11 Remacle M, Lawson G, Jamart J et al (1997) Co2 laser in the diagnosis and treatment of early cancer of the vocal fold. Eur Arch Otorhinolaryngol 254(4):169–176 Chiesa F, Tradati N, Costal L et al (1991) Co2 laser surgery in laryngeal cancers: three year results. Tumori 77(2):151–154 McGuirt WF, Koufam (1987) Endoscopic laser surgery. 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Ann Otol Rhinol Laryngol 108(9):819–827 Robbins KT, Triantafyllou A, Suárez C3,4, López F5, Hunt JL (2018) Strojan P7, Williams MD8, Braakhuis BJM9, De Bree R10, Hinni ML11, Kowalski LP12, Rinaldo A13, Rodrigo JP5, Poorten VV14, Nixon IJ15, Takes RP16, Silver CE17 and Ferlito. Surgical Margins in Head and Neck Cancer: Intra- and Postoperative Considerations. Clinics in Oncology. | Volume 3 | Article 1494 Martin C, Ja¨ckel MD, Petra Ambrosch MD, Alexios Martin MD, Wolfgang Steiner MD (February 2007) Impact of Re-resection for Inadequate Margins on the Prognosis of Upper Aerodigestive Tract Cancer Treated by Laser Microsurgery. Laryngoscope 117. 10.1097/01.mlg.0000251165.48830.89 Krespi YP, Meltzer CJ (1989) Laser surgery for vocal cord carcinoma involving the anterior commissure. Ann Otol Rhinol Laryngol 98(2):105–109. 10.1177/000348948909800204 Rifai M, Khattab H (2000 Sep-Oct) Anterior commissure carcinoma: I-histopathologic study. Am J Otolaryngol 21(5):294–297. 10.1053/ajot.2000.16159.PMID Peretti G, Piazza C, Cocco D, De BL, Del BF, Redaelli De Zinis LO, Nicolai P (2010) Transoral CO2 laser treatment for Tis–T3 glottic cancer: The University of Brescia experience on 595 patients. Head Neck 32:977–983 Caglar Eker O, Surmelioglu M, Dagkiran O, Kaya I, Tanrisever B, Arpaci (2024) Bedir Kaya, Sevinc Puren Yucel Karakaya & Elvan Onan. Transoral laser microsurgery for T1 glottic cancer with anterior commissure: Identifying clinical and radiological variables that predict oncological outcome. Head and Neck. Published: 29 February 2024. Volume 281, pages 2597–2608 Rifai M, Mebed H, Bassiouni M (1990) Direct extension of laryngeal carcinoma to the skin of the neck. J Laryngology Otology 104(10):824–826 Stell PM, Van Den Broek P (1971) Stomal recurrence after laryngectomy: aetiology and management. J Laryngology Otology 85(2):131–140 Sessions DG (1976) Surgical pathology of cancer of the larynx and hypopharynx. 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Feb, 2026 Reviews received at journal 21 Feb, 2026 Reviews received at journal 21 Feb, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviewers invited by journal 20 Feb, 2026 Editor assigned by journal 22 Dec, 2025 Submission checks completed at journal 22 Dec, 2025 First submitted to journal 19 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8402375","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":595838981,"identity":"c14e5548-153b-4812-848d-351eaa0f9249","order_by":0,"name":"Mohamed Sadek Rifai","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Sadek","lastName":"Rifai","suffix":""},{"id":595838982,"identity":"e6e699a1-9690-4c6a-b209-713f2e63a3b2","order_by":1,"name":"Magdy M. 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(White arrow).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8402375/v1/73c99c88e73fd3cf628dea48.jpeg"},{"id":103401003,"identity":"3ca928a5-7328-46cb-912d-2c2bba099c01","added_by":"auto","created_at":"2026-02-25 09:25:15","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":541677,"visible":true,"origin":"","legend":"\u003cp\u003eLaryngectomy specimens showing malignant tumor infiltrating the AC.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8402375/v1/026a99a8c16fbcd152a59ded.jpeg"},{"id":103401309,"identity":"4a78dba2-8bf4-43a9-b19d-a42b5183a18c","added_by":"auto","created_at":"2026-02-25 09:26:21","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":32186,"visible":true,"origin":"","legend":"\u003cp\u003eTransverse section demonstrating glottic carcinoma with invasion of the (AC), and absence of an intervening tissue plane. (T Tumor C Cartilage) (H\u0026amp;E; original magnification x 200)\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8402375/v1/259ebbf0c23de74fa918b7a3.jpeg"},{"id":103401038,"identity":"528578f3-9550-4dc6-9253-6bbf460e8584","added_by":"auto","created_at":"2026-02-25 09:25:23","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":265272,"visible":true,"origin":"","legend":"\u003cp\u003eHistologic section showing keratinizing squamous cell carcinoma with an expanding border abutting the cartilage. The section showed no tissue barrier between the tumor and the cartilage (arrow) (H\u0026amp;E; original magnification 200). (T Tumor C Cartilage)\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8402375/v1/9d8efc4df016bd08dd70e2c5.jpeg"},{"id":103401037,"identity":"c0ae40e3-9d06-4580-8c6e-278fae7e5122","added_by":"auto","created_at":"2026-02-25 09:25:23","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":303620,"visible":true,"origin":"","legend":"\u003cp\u003eNon-keratinizing squamous cell carcinoma, showing cartilage invasion. (Hematoxylin and Eosin; original magnification × 200). (T Tumor, C Cartilage).\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8402375/v1/6b50599eb0f4626f9bb29e82.jpeg"},{"id":103401857,"identity":"db21565a-415d-42cc-9d3e-3157b32da657","added_by":"auto","created_at":"2026-02-25 09:27:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1916458,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8402375/v1/5a4331ea-25ec-4fc8-a53e-5e3b472eef7d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Limitations of Trans-Oral Endoscopic Laser Resection in the Management of Laryngeal Cancer with Anterior Commissure Involvement: Retrospective, Cross sectional studies and review of clinical experience","fulltext":[{"header":"Introduction","content":"\u003cp\u003e(TLS) developed as a larynx-preserving treatment for early-stage (T1s, T1a) laryngeal cancer localised to the mid-vocal cord without (AC) involvement.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Its use expanded to T1b and T2 lesions\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e and \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, including those requiring extended cordectomies with or without arytenoid cartilage resection, and occasionally involving perichondrium or the cricothyroid membrane\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLaser debulking, then external beam radiation, was also used \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e ad \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The term \"Laser irradiation\" was surprisingly quoted \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHowever, high recurrence rates after TLS, especially in T1b and T2 glottic cancers involving the (AC), led some to favour external conservation approaches for T1b, T2 \u003csup\u003e11\u003c/sup\u003e, and early T3 lesions, cautioning against TLS for T3 tumors \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, and \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eConversely, many studies reported using (TLS) \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e \u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e and/or (RT) \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e \u0026ndash; \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e for advanced (T2-T4) glottic and selected supra-glottic carcinomas, often combined with neck dissection and/or (RT) \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e \u0026ndash; \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e and 20\u0026ndash; \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, sometimes overlooking the anterior commissure and sub-glottic region.\u003c/p\u003e \u003cp\u003eSurgical lasers demonstrated promising outcomes in the management of laryngeal malignancies, including advanced stage III and IV tumors, as evidenced by a substantial body of literature. These publications frequently introduce novel terminologies, including local control, disease-free survival, disease-specific survival, and \u0026hellip;, potentially overshadowing the conventional five-year cure rate. The increasing complexity of statistical methodologies employed to analyse treatment outcomes appears driven by a desire to refine results and emphasize the perceived benefits of surgical laser interventions. Modern statistics often obscure rather than clarify the real impact of surgical lasers, contradicting clinical experience and research that dispute claims of impressive results.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e \u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eKasr Al Aini Hospital's Otolaryngology Department, a tertiary referral centre in Egypt, manages approximately 150 outpatient consultations and performs 12 daily surgeries (including three major cases) six days a week. It also provides 24/7 emergency services daily. A retrospective review of hospital records from May 2023 to April 2025 identified only 32 patients with recurrent T1/T2 laryngeal carcinoma treated with TLS during those two years.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis retrospective analysis examined 32 patients diagnosed with T1/T2 laryngeal squamous cell carcinoma treated with TLS between May 2023 and April 2025. 19 patients with T1N0M0 tumours and 13 patients with T2N0M0 tumours were included. Within the T1N0M0 cohort, 12 lesions abutted the (AC), and 8 patients received adjuvant (RT). In the T2N0M0 group, nine cases exhibited clinical AC involvement, and all 13 patients received post-TLS RT.\u003c/p\u003e \u003cp\u003eOf these 32 patients, 22 experienced recurrence within 3\u0026ndash;24 months.All underwent diagnostic staging. Subsequent surgical management, based on the current stage, consisted of either conservative laryngeal surgery (CLS) or total laryngectomy (TL), with or without neck dissection (ND). Patients with T3 or T4 lesions received (DXT) if they had not previously received a full dose after (TLS). Minimum follow-up was 2 years.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA Cross-sectional study of five random laryngectomy specimens (2 CLS, 3 TL), was performed to determine the relationship between recurrent tumour and cartilage in the (AC) region.\u003c/p\u003e \u003cp\u003eEthical approval:\nThis retrospective analysis was conducted after obtaining approval from the Research Ethics Committee (Approval No: N-293-2025). The requirement for informed consent was waived due to the retrospective nature of the study.\n\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA retrospective review of hospital records identified 32 patients diagnosed with T1/T2 laryngeal carcinoma treated with TLS between May 2023 and April 2025.\u003c/p\u003e\n\u003cp\u003eOut of 19 patients with T1N0M0 glottic lesions, 13 patients (68.4%) experienced a recurrence. Among these, nine patients still had T1N0M0 lesions that involved the (AC) and underwent (CLS). Lesions were more aggressive in the remaining four patients. One had T3N0M0 lesions and underwent (CLS). The remaining three patients had T4N1M0 tumors and underwent (TL) along with (ND).\u003c/p\u003e\n\u003cp\u003eRecurrence occurred in 69.2% (9/13) of patients with T2N0M0 glottic lesions. Of these, five T2N0M0 patients with (AC) involvement underwent (CLS). Three T3N2M0 and one T4N2M0 patient underwent (TL) and (ND).\u003c/p\u003e\n\u003cp\u003eOf 32 patients, nineteen presented with T1 disease and thirteen with T2. Following (TLS) failure, 22 patients (54%) experienced recurrence within 3-24 months. Of these, 14 (63.6%) recurred at the same initial stage, while eight (36.6%) progressed to a more advanced stage. There were fifteen patients (68.18%) who had (CLS), and seven (31.8%) had (TL).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Cartilage invasion manifested through three distinct mechanisms. These included direct invasion without a clear tissue plane of demarcation (Figure 3), abutment exhibiting an expanding margin lacking a defined barrier (Figure 4), and infiltration via satellite foci of squamous cell carcinoma (SCC) (Figure 5).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhile initially considered effective for early laryngeal cancer, TLS has significant limitations. High recurrence rates, particularly in T1b and T2 glottic carcinomas \u003csup\u003e24\u003c/sup\u003e and the risk of disease progression, as demonstrated in this study, suggest TLS may not be the best option for many patients.\u003c/p\u003e\n\u003cp\u003eLaser technology, while sometimes presented as revolutionary, functions primarily as a precise surgical instrument with limited impact on overall homeostasis\u003csup\u003e25\u003c/sup\u003e. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe enthusiasm surrounding lasers has led to the introduction of terms such as \u0026ldquo;laser debulking\u0026rdquo;\u003csup\u003e8\u003c/sup\u003e, \u0026ldquo;laser irradiation\u0026rdquo;\u003csup\u003e10\u003c/sup\u003e, and \u0026ldquo;thermal sterilisation\u0026rdquo;, potentially overstating their unique capabilities.\u003c/p\u003e\n\u003cp\u003eResidual carcinoma in resection specimens correlated with increased loco-regional failure. The conventional 5 mm margin for laryngeal cancer resection is increasingly being challenged \u003csup\u003e26-27\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eManagement of early laryngeal cancer requires careful assessment of (AC) involvement, a key prognostic factor. While the (AC) is involved in about 20% of early glottic squamous cell carcinomas, isolated tumors there are uncommon (1% of all glottic cancers)\u003csup\u003e28\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTumor spread can involve the contralateral vocal cord, thyroid cartilage, and pre-epiglottic space, influencing treatment and prognosis. Under staging is frequent (24%)\u003csup\u003e\u0026nbsp;29\u003c/sup\u003e, potentially leading to T1 lesions being reclassified as T4 based on deep cartilage invasion. Sub-glottic extension also poses a challenge, as sub-mucosal spread can occur through the cricothyroid membrane.\u003c/p\u003e\n\u003cp\u003eThis study emphasises (AC)\u0026rsquo;s critical role in treatment planning for malignant laryngeal tumors. A retrospective review of 32 patients (19 T1, 13 T2) treated with TLS revealed a 54% recurrence rate (22 patients) within 3-24 months, with clinical AC involvement observed in 63.6% (14) of initial lesions, further underscoring the AC\u0026apos;s significance.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Underestimating tumour extent and inadequately addressing cartilage invasion increases recurrence risk due to incomplete resection. While adjuvant (RT) is recommended to improve local control \u003csup\u003e8, 10, 20 and 30\u003c/sup\u003e, it has inherent risks and may not fully compensate for the limitations of (TLS) \u003csup\u003e31\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003ePatients often require total laryngectomy following unsuccessful attempts to preserve the larynx through partial resection or (RT). Salvage surgery in these instances carries a significant risk of operative and postoperative complications\u003csup\u003e32\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003ePreoperative tracheostomy in patients with laryngeal carcinoma has been associated with an increased risk of stomal recurrence, potentially due to implantation of tumor cells around the tracheostomy \u003csup\u003e33\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe presence of tumor in the resected margins correlates with a higher incidence of local recurrence and a less favourable prognosis \u003csup\u003e34\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eSeveral factors contribute to positive margins in partial laryngeal surgery. The nature of the surgery often necessitates resection close to the tumor. Furthermore, anatomical considerations, such as the reluctance to sacrifice the (AC) and opposite vocal fold, can contribute to involved margins at these sites \u003csup\u003e35\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMeticulous patient selection and precise tumor staging are paramount for successful (TLS). In advanced-stage lesions, open surgical techniques may be more appropriate. Surgical re-excision to achieve histologically negative margins is mandatory. This is challenging with (TLS), particularly for large tumors (T2-T4) or those involving the (AC). Recurrence following (TLS) or definitive (RT) may necessitate (TL), resulting in loss of laryngeal function. Specifically, involvement of the (AC), as well as disease extension to other vocal cord regions, the supra-glottis, or the sub glottis, significantly elevates the risk of recurrence after (TLS) and (RT), thus warranting consideration of more conservative surgical strategies in these clinical scenarios.\u003c/p\u003e\n\u003cp\u003eOptimal therapeutic selection necessitates collaborative decision-making between patients and surgeons. While respecting patient autonomy is paramount, the pursuit of trans-oral laser microsurgery (TLM) or radiotherapy (RT) exclusively to circumvent laryngectomy is professionally and ethically questionable without a rigorous evaluation of oncological principles and associated risks. Surgeons bear the responsibility of providing patients with a comprehensive explanation of all potential risks.\u003c/p\u003e\n\u003cp\u003eNo statement captures this dilemma more wisely than this quotation: \u0026quot;Radiotherapy is unlikely to cure cancer due to its limitations, evidenced by static survival rates over the past two decades. Poor outcomes in advanced head and neck cancer care may obscure underlying mismanagement, due to the disease\u0026apos;s natural progression, potentially misleading general practitioners and even other surgeons.\u003csup\u003e36\u003c/sup\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e1. Mohamed Sadek Rifai: main surgeon 2. Magdy M. Mansy: pathology study of samples3. Muhammed Abd Al-lateef Muhammed Abd Al-lateef \u0026amp; 4. Mena Esmat Abdelmalek : reviewed the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEckel HE (1993) Topographical and clinico-oncologic analysis of locoregional recurrence after transoral laser surgery for laryngeal cancer. Laryngorhinootologie 72:8 406\u0026thinsp;\u0026ndash;\u0026thinsp;11\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRemacle M, Lawson G, Jamart J et al (1997) Co2 laser in the diagnosis and treatment of early cancer of the vocal fold. Eur Arch Otorhinolaryngol 254(4):169\u0026ndash;176\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiesa F, Tradati N, Costal L et al (1991) Co2 laser surgery in laryngeal cancers: three year results. Tumori 77(2):151\u0026ndash;154\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGuirt WF, Koufam (1987) Endoscopic laser surgery. An alternative in laryngeal cancer treatment. 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Early clinical experience with continuous CO2 laser. Ann Otol Rhinol Laryngol 81:791\u0026ndash;798. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/000348947208100606\u003c/span\u003e\u003cspan address=\"10.1177/000348947208100606\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Trans oral endoscopic laser resection (TLS), anterior commissure (AC), Radiotherapy (RT) Conservative laryngeal surgery (CLS), Total laryngectomy (TL), Neck dissection (ND), Squamous cell carcinoma (SCC)","lastPublishedDoi":"10.21203/rs.3.rs-8402375/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8402375/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAim of the work: This study assesses the limitations of transoral laser microsurgery (TLM) for early-stage laryngeal cancer involving the anterior commissure (AC), specifically examining the relationship between recurrence and thyroid cartilage invasion.\u003c/p\u003e \u003cp\u003ePatients and methods: A retrospective review of 32 T1-T2 glottic carcinoma patients treated with TLM between May 2023 and April 2025 analysed recurrence and progression over 3\u0026ndash;24 months. Concurrently, a cross-sectional analysis of five laryngectomy specimens from recurrent cases evaluated AC involvement and thyroid cartilage invasion.\u003c/p\u003e \u003cp\u003eResults: The cohort comprised 19 T1 and 13 T2 tumors. Recurrence occurred in 22 patients (54%), with 14 (63.6%) recurring at the same stage and 8 (36.4%) progressing. Salvage treatment consisted of 15 conservative surgeries (68.2%) and 7 total laryngectomies (31.8%). Histological analysis of all five laryngectomy specimens revealed tumor involvement of the cartilage.\u003c/p\u003e \u003cp\u003eConclusions: AC involvement significantly impacts prognosis in early-stage laryngeal cancer. Given the increased recurrence risk after TLM or DRT associated with AC, vocal cord, supraglottic, or subglottic involvement, and the potential need for total laryngectomy, conservative surgical approaches should be considered cautiously in these cases.\u003c/p\u003e","manuscriptTitle":"The Limitations of Trans-Oral Endoscopic Laser Resection in the Management of Laryngeal Cancer with Anterior Commissure Involvement: Retrospective, Cross sectional studies and review of clinical experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-25 09:23:06","doi":"10.21203/rs.3.rs-8402375/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-23T18:07:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-21T09:15:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-21T08:46:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"262326879401151120908920703505827154837","date":"2026-02-20T15:33:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199303893828531476629893778115769884156","date":"2026-02-20T07:43:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-20T07:02:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-22T09:08:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-22T09:05:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Otolaryngology","date":"2025-12-19T08:09:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0fca5a2b-92ab-4107-829e-3e1c73607f25","owner":[],"postedDate":"February 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-03T20:09:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-25 09:23:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8402375","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8402375","identity":"rs-8402375","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}