R. Smucler, J. Mazanek, Department of Stomatology, 1^st Faculty of Medicine, Charles University and General University Hospital, Prague, CZ,  Head Doctor: Prof. MUDr. J. Mazánek, DrSc.

 

Summary

The objective of this paper is to analyse the potential of laser excision and interstitial hyperthermia in improving the quality of life for patients with 3^rd and 4^th stages of malignant head and neck tumours. The authors have made use of the classification provided by the University of Washington, Quality of Life, modified for malignity in the head and neck, in its 4^th version. Twenty patients have completed questionnaires in which they evaluated their conditions in 12 categories before a laser operation, on the day after the operation and 6 weeks after the operation. In total, there was an increase of 16.41 points reported, which represents a subjective improvement in the quality of life of 70.32 %. According to the response to the therapy, there seems to be an unequivocal benefit for patients with a primarily low quality of life; patients with less intensive complications have reported a temporary deterioration over a short period after the operation. In order to ensure an objective indication, it would be desirable to carry out an individual mathematic modelling of the possible benefits for patients, based on the UW-QOL classification.

 

Key words: 

laser interstitial hyperthermia, head and neck tumours, palliative therapy, quality of life, diode laser

 

Introduction

Gradually developing classification of the quality of life enables us to compare various methods used in palliative therapy for patients with advanced tumour diseases. The outcome should comprise not just a comparison of the methods, but also the possibility of compiling an individual therapy plan for every patient. For our purposes, we looked at several alternatives and selected the 4^th version of the Washington University Quality of Life classification, 2001, for head and neck tumours, covering 12 aspects of the disease.

Another resource was based on our experience with malignity palliation using a diode laser. We have proven in our previous studies that laser excision and interstitial hyperthermia are safe methods which may be repeated even in patients heavily exposed to medication. Laser offers an extension of the indication range concerning the surgical reduction of tumour material, which still remains the most effective method of comprehensive oncology therapy. We have also proven that the anticipated acceleration of tumour disease "in vivo" is doubtful because - compared to a clearly faster cellular proliferation after laser irritation - it is necessary to consider the therapeutic effects of palliation, particularly with regards to improved nutrition, hydration and the psyche. The last issue concerning placement of  laser on the list of  therapeutic palliative methods consisted of the evaluation of the increased quality of life, which has become the subject of this paper.

 

Material and methodology 

Instrumentation:

We used a diode laser Ceralas 25 (Germany), wavelength - 980 nm, output measured at laser outlet - 25 W, output adjustable by 1 W, quasi-pulse length – 0.01- 99 s, guide ray – diode laser 670 nm, transmission – standard silicon flexible fibre.

 

Selection of Patients:

We have selected patients for the purposes of our research according to the following criteria:

1. Patients min. T2-4; N1-3; M 0-1

2. Patients contraindicated for radical conventional surgical treatment

3. Patient's written consent to the experimental character of the method.

The prospective file comprised patients who have fulfilled the criteria above, except for dying patients with no hope for the evaluation of results after 6 weeks, due to major complications of oncological disease – e.g. progressive bronchopneumonia terminalis.

Despite the original plans, varying reactions of the patients made it necessary for us to divide the patients into the following categories, according to their current conditions:

• Group A – lower reduction in the quality of life

• Group B – medium reduction in the quality of life

• Group C – strong reduction in the quality of life.

The numbers allocated to individual patients correspond to their rank, with no indication of the groups described above. For changes sorted by individual groups, see Diagram 1.

 

Methodology for laser interstitial hyperthermia in neck nodes

Laser induced interstital hyperthermia (LIIT) is an intensively developing method of minimally invasive surgery aimed at local destruction of tumours based within anatomical structures. Laser applied by the means of puncture technique through an introduced laser fibre results in a very clearly defined area of coagulation necrosis. Since its premiére in 1983 (Ascher) this method has been successfully applied in brain (Ascher), liver (Brown, Masters), arterial system (Berlien), prostate (Watson, Hofstetter) etc. 

The purpose of our work was to apply  LIIT with no ancillary monitoring methods, using only palpation and aspection (thanks to red laser pilot beam). As a model application we have chosen metastases of oral cavity tumours into neck nodes. In theory, thermal capacity of the blood flowing through major neck vessels is sufficient to prevent the walls of these vessels be thermally damaged. Lymph glands changed by metastases are very well palpable. In the event of an acute complication this area is surgically accessible more easily than for instance the area of liver.

The operations were performed with no special medication and with no changes in the chronic medication at the treatment room (we did not make use of an aseptic operating room). After disinfecting the skin with iodine-alcohol solution, we infiltrated 4% Supracain in order to anaesthetise the entire area. Afterwards, we applied an injection needle above the utmost area of the pathological focus. We inserted a laser fibre (diameter of 1 mm) without a plastic package in the needle. The tip of the laser fibre exceeded the point of the needle by 2 mm. After this, we exerted an output of 10W in a pulse mode (pulse length / interval length 0.5 s / 0.5 s) and affected the lesion until it disintegrated. Wherever we failed to destroy the pathological lesion completely, we proceeded with another puncture at a corresponding distance. We recorded the number of application points and the total irradiation doses. Unlike in classical methodology, placing an emphasis on closing the channel after a laser operation, e.g. with a tissue binder, we always chose one of the application points (of a larger focus) and damaged the skin thermally in order to create a point fistula for drainage of the wound. After the operation, we applied an absorbent bandage. In case of pain, we administered analgesics (orally). We replaced the absorbing bandage at least once every day (as necessary).

 

Fig. 1: LIIH of neck nodes - application of the laser fibre

Methodology for laser excision

We infiltrated 4 % Supracain in order to anaesthetise the tumour and the surrounding area. We worked only in a continual mode, output 6 - 25 W. We modified the distance between the fibre and the tumour within a range of 0-10mm, thus changing the ratio between the vaporization and coagulation of the tissue in order to avoid bleeding. We have always aimed at complete ablation of the tumour. When this was technically impossible (particularly due to bone proliferation), we tried to reduce the tumour as much as possible. We left the wound to heal per secundam intentionem without suturing.

 

Fig. 2: Wounds immediately after laser vaporization, the edge of irreversible thermal damage is clearly visible

 

Evaluation

Each patient completed the Questionnaire issued by the University of Washington Quality of Life, three times in total, i.e. before laser operation, on the day after the operation and during a check-up 6 weeks after the operation. The classification focuses on 12 characteristics: pain, appearance, patient's activity, ability to rest, swallow, chew, speak, motility of the shoulder, taste, salivation, mood disorders and anxiety. 

Each answer was given within the range of 0 (none quality) to 100 (full). The final classification value is based on the arithmetic mean of the ascertained data. As the values are expressed in a range of 0 - 100, it is possible to consider this to be a percentage expression of the quality of life. The questionnaires were completed by the attending physician together with the patients, so that the patients did not know the values allocated to individual answers. For ethical reason, the patients were not informed of the measured results.

 

Results

For clinical results, see Table 1.

 

Group	No.	Diagnosis	Before palliation	Day 2 after palliation	Cange	Week 6 after palliation	Change	Total change	Mean change
	MKN	UW-QOL	UW-QOL	UW-QOL	UW-QOL	UW-QOL	%	in group
A	1	C02.2	83,42	70,92	-12,50	89,66	6,24	7,48%
A	5	C42.2	82,39	58,42	-23,97	81,33	-1,06	-1,29%
A	9	C02.1	82,39	66,75	-15,64	88,63	6,24	7,57%
A	15	C02.2	83,42	73,00	-10,42	89,66	6,24	7,48%
A	19	C02.2	79,67	70,92	-8,75	86,92	7,25	9,10%	6,07%
B	2	C02.2	36,75	50,67	13,92	60,50	23,75	64,63%
B	3	C44.3	34,67	47,92	13,25	64,67	30,00	86,53%
B	7	C64	39,50	52,75	13,25	66,75	27,25	68,99%
B	8	C80	32,58	50,00	17,42	58,42	25,84	79,31%
B	11	C02.2	39,50	50,67	11,17	61,92	22,42	56,76%
B	16	C02.1	39,83	43,75	3,92	40,92	1,09	2,74%
B	20	C02.1	36,75	46,50	9,75	64,67	27,92	75,97%	62,13%
C	4	C64	7,58	9,66	2,08	7,58	0,00	0,00%
C	6	C02.1	13,83	38,91	25,08	43,08	29,25	211,50%
C	10	C64	15,92	34,75	18,83	34,75	18,83	118,28%
C	12	C02.1	13,17	30,58	17,41	38,92	25,75	195,52%
C	13	C02.1	15,92	36,17	20,25	41,00	25,08	157,54%
C	14	C64	20,08	32,67	12,59	34,75	14,67	73,06%
C	17	C02.2	18,00	41,00	23,00	43,08	25,08	139,33%
C	18	C80	13,83	20,17	6,34	20,17	6,34	45,84%	117,63%
	Mean			6,85		16,41	70,32%

 

Diagram 1: Time pattern of the UW-QOL index, depending on the intensity of complications

 

Figure 3: Comparison of subjective evaluation by patient:  12,1 (UW-QOL)  Loneness, zero social activity, frequent aspiration, alimentation very difficult, patient objectively hypercritical	Figure 4: Comparison of subjective evaluation by patient: 84,6 (UW-QOL) Extraordinarily strong role of the family, loss of three-dimensional vision, alimentation and respiration retained, Objective overvaluation

 

Discussion

It is difficult to obtain a randomised and statistically valuable file of patients within a single medical centre. However, we are able to claim – even without a multicentre study including a corresponding number of patients – that laser interstitial hyperthermia and laser excision are most likely to improve the qualify of life in patients with the 3^rd and 4^th stages of the disease. We identified no significant complications during the course of the study which might present a threat for the patients. We are, therefore, able to consider the use of this method to be beneficial for the patients.

 

Key aspects for discussion:

• Deterioration of conditions immediately after the operation – patients with a lesser intensity of the disease have accentuated certain complications after their operations – pain, oedema, odour from the healing wound or a visible wound. Other patients also reported similar complications. However, the final results of the operation (reduction of the tumour, better speech, swallowing, mobility and particularly improvement of the psyche) outweighed the negative aspects. This means that it is necessary to analyse the improvements and complications in individual parameters before designating the operation. Subsequently, it is necessary to calculate the anticipated coefficient after the operation and before recovery. We may designate the operation only if the coefficient increases significantly. Without the UW-QOL classification, a surgeon may easily make a mistake by emphasising only one of the factors (e.g. psyche). According to the results, it is necessary to be careful with patients with a high value of UW-QOL, who may feel temporary complications after the operation without a significant improvement in the long-term perspective.

 

• Postponing of palliative surgery – primary onco-surgery considers a tumour to be an acute disease, with a risk of delay. Our results indicate that palliative medicine may have different rules. It seems necessary to wait until the UW-QOL decreases, i.e. until the benefits outweigh some temporary complications. Provided that a locally irritated tumour proliferates faster, it is necessary to postpone irritation as necessary.

 

• Factor of relative subjective improvement – Groups B and C differed in the relative value much more than in the value of an improvement of the UW-QOL index. This is again different to what is reported by classical oncology. We may consider the greatest benefit in patients whose poor conditions and lack of other alternatives will intensify the effects of laser palliation, particularly as regards the psychosomatic aspects.

 

• Localisation factor – The results are excellent when compared to the results of similar studies in other parts of the body in stages 3 and 4 of the disease. In addition to improvements concerning the parameters of mood disorders and anxiety, which is a general benefit in palliation, a significant role – particularly in the facial area – is played by appearance, patient activity, ability to rest, swallow, chew, speak and move the shoulders. Based on an increase in several parameters, we succeed in improving the UW-QOL index considerably, although maintaining the classification values at a certain level is considered a success in some other anatomical localities.

 

• Economic aspects – The direct costs per operation do not exceed CZK 200. We may, therefore, claim that there is no need to consider possible designation with respect to economic reasons, which is also an important aspect.

Conclusion

1. Combined laser palliative surgery increases the quality of life in patients with the 3^rd and 4^th stages of the disease, with a short-term or no deterioration of the conditions

2. Planning a target value of the UW-QOL index is very important before a decision concerning the indication of palliative therapy.

 

Possible directions of further research

• Carry out comparison of laser palliative surgery with other methods of palliative surgery of head and neck tumours

• Evaluate combination of laser excision with hyperthermia in lower stages of tumour diseases.

 

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Note: This paper was issued with financial support provided by the Internal Grant Agency of the Czech Ministry of Health – Grant No. 5887-3.