Surgery in the Management of Laryngeal and Hypopharyngeal Carcinoma

Abstract

Currently, a multitude of treatment options are available for laryngeal and hypopharyngeal carcinoma. Surgery should be considered a viable option in the definitive management of almost all laryngeal and hypopharyngeal tumors, regardless of stage. The characteristics of the primary tumor, as well as the status of the at-risk regional lymph nodes, are critical in the development of a treatment plan. In addition to the patient’s history and physical examination, a comprehensive staging evaluation is required that includes endoscopy, biopsy, and imaging. A patient’s comorbidities and functional status are also important factors to consider during the development of a treatment plan. Surgery as a single modality therapycanbeofferedforearly-stagedisease,andthecombination ofsurgery with adjuvanttherapy(radiotherapywithorwithout chemotherapy) should be used for advanced-stage disease. Surgery also plays a critical role in the management of recurrent or persistent disease, especially after initial nonoperative management. Because survival differences do not exist between surgical and nonsurgical therapies for most clinical scenarios, each patient should undergo a multidisciplinary evaluation to discuss all options before therapy. During the assessment of a laryngeal cancer, the tumor should be classified as either glottic or supraglottic, with isolated subglottic primaries rarely seen. Defining the site of origin, as well as clearly delineating the extent of tumor, is mandatory in developing a surgical plan. Deciding on the surgical options for the primary tumor, as well as whether to address the regional nodal basins, is determined from these tumor characteristics. In general, early glottic tumors are amenable to partial laryngeal resection. Regional metastases are uncommon at presentation and the potential for occult nodal disease is low, making neck dissection usually unnecessary.Moreadvancedglotticprimaries mightstill beamenable to partial laryngeal resection, but total laryngectomy and neck dissection could be required. Supraglottic tumors are also frequently amenable to partial laryngeal resection, but, again, in some instances, total laryngectomy might be required. Most supraglottic tumors, regardless of T stage, require therapy directed to the regional lymph nodes, given the high risk of regional spread. Neck dissection for the regional nodal basin is usually required bilaterally, given the richlymphatics of the supraglottisand the relatively infrequent occurrence of well-lateralized supraglottic primary tumors. Selected laryngeal, as well as hypopharyngeal, carcinomas are best managed by total laryngectomy (with postoperative adjuvant therapy) as the initial treatment. The most common scenario requiring definitive total laryngectomy is a case in which extensive cartilage erosion or extralaryngeal extension of the tumor is present. Patients with these extensive tumors have been shown to have worse disease control when treated by radiotherapy alone compared with surgery and postoperative radiotherapy (1). In the recent multimodality nonoperative organ preservation trials, patients with these extensive T4 tumors were more likely to need salvage laryngectomy or were excluded from participation in the trial (2, 3). The other clinical scenario in which total laryngectomy should be considered is for patients who have life-threatening aspiration at diagnosis. Several surgical organ preservation options exist for laryngeal tumors. These options can beclassified as either openvs. endoscopic procedures. Historically, open laryngeal preservation surgery for glottic tumors included cordectomy or vertical partial laryngectomy and, for supraglottic tumors, included horizontal partial laryngectomy. Near-total laryngectomy has been used for organ preservation in more advanced glottic and supraglottic tumors. Currently, with the success of tracheoesophageal prostheses for speech restoration after total laryngectomy and the success of extended partial laryngeal resection for more advanced tumors, this procedure is rarely performed. More recently, supracricoid laryngectomy and endoscopic laser resection have gained significant popularity in the management of both glottic and supraglottic carcinomas.