Conservation Laryngeal Surgery Research Articles

Supracricoid laryngectomy with cricohyoidopexy for recurrence of early-stage glottic carcinoma after irradiation. Long-term oncological and functional results

ConclusionsThese results suggest that, in selected cases, SCL-CHP may be used to treat laryngeal carcinomas after radiation failure, with good oncological and functional results.ObjectivesRadiotherapy and surgery are believed to be equally effective and highly successful in the management of T1-staged glottic carcinomas. An almost normal post-therapy voice is considered the main advantage of irradiation over the surgical approach. On the other hand, when a tumour recurs after radiotherapy, it is more likely to extend beyond its original site, making total laryngectomy necessary in most cases. However, in selected cases, conservative laryngeal surgery is possible. At present only a few reports in the literature have documented the oncological and functional outcome of supracricoid laryngectomy with cricohyoidopexy (SCL-CHP) in the treatment of laryngeal recurrence after irradiation.Material and methodsWe describe seven cases of rT2–T3 laryngeal squamous cell carcinomas that recurred after radiotherapy and were treated with salvage SCL-CHP between 1989 and 1997 at the Department of Otolaryngology, University of Ferrara. The disease-free interval following initial radiotherapy ranged from 13 to 132 months (mean 54 months) in 6 patients; 1 patient underwent 2 courses of irradiation treatment 103 and 8 months prior to surgery.ResultsThe mean post-SCL-CHP follow-up period exceeded 10 years (range 72–173 months). Only the patient who underwent 2 courses of radiation therapy before surgery experienced laryngeal recurrence 48 months after surgery. All patients were decannulated and recovered the ability to swallow. Vocal quality was significantly rough and breathy but was satisfactorily intelligible in all patients. Four patients had wound healing problems; 1 of them developed a laryngotracheocutaneous fistula 15 months after SCL-CHP as a consequence of chondronecrosis, prompting total laryngectomy.

Definitive treatment of intermediate stage laryngeal squamous cell (SCC/L) cancer with chemotherapy (CT)

5533 Background: Surgery and/or radiotherapy (RT) are definitive local treatment modalities for intermediate stage SCC/L. Methods: We have evaluated paclitaxel (T) 175/mg/m2 day 1, ifosfamide (I) 1000mg/m2/days 1–3 (with mesna), and cisplatin (P) 60mg/m2 day 1 for previously untreated patients (pts) with SCC/L, stage T2 –4, N0 –1, M0. To be eligible, the primary tumor had to be considered resectable with conservation laryngeal surgery. After TIP x 3, pts achieving partial disease regression (PR) proceeded to surgery. Patients achieving a histologic complete response (CR) received an additional 3 CT cycles and no local treatment. A preliminary report was provided previously (FRK Proc ASCO #906, 2002). This is a report of more mature results with focus on CR patients treated with chemotherapy alone. Results: From 10/97 until 8/03, 29 patients (20 M, 9 F; median age 58 years, range 20–79) were entered. Tumor stage ranged from T2 N0 - T4 N1; median follow up is 36 months. Ten pts (34%) achieved CR and 17 (59%) PR after CT. CR patients were monitored monthly. Videostroboscopy will show tumor shrinkage, normalization of mucosa, and dramatic improvement in phonatory approximation in 5 of 5 pts with true vocal cord involvement. Two of 10 CR patients have developed local recurrence, with one living and disease-free after RT. Eight pts are alive and recurrence-free. Of the entire group of 29, 6 pts have developed recurrence (6 local/regional and 1 distant). Two patients have required total laryngectomy and 3 RT. Twenty-four of 29 pts are alive and disease-free. One patient died of a second primary cancer. Conclusions: Systemic chemotherapy for intermediate stage SCC/L provides durable disease remission in some pts. This favorable early experience suggests that SCC/L is potentially curable with systemic therapy. However, treatment of larynx cancer with chemotherapy as a single modality remains highly experimental. No significant financial relationships to disclose.

Definitive treatment of intermediate stage laryngeal squamous cell (SCC/L) cancer with chemotherapy (CT)

5533 Background: Surgery and/or radiotherapy (RT) are definitive local treatment modalities for intermediate stage SCC/L. Methods: We have evaluated paclitaxel (T) 175/mg/m2 day 1, ifosfamide (I) 1000mg/m2/days 1–3 (with mesna), and cisplatin (P) 60mg/m2 day 1 for previously untreated patients (pts) with SCC/L, stage T2 –4, N0 –1, M0. To be eligible, the primary tumor had to be considered resectable with conservation laryngeal surgery. After TIP x 3, pts achieving partial disease regression (PR) proceeded to surgery. Patients achieving a histologic complete response (CR) received an additional 3 CT cycles and no local treatment. A preliminary report was provided previously (FRK Proc ASCO #906, 2002). This is a report of more mature results with focus on CR patients treated with chemotherapy alone. Results: From 10/97 until 8/03, 29 patients (20 M, 9 F; median age 58 years, range 20–79) were entered. Tumor stage ranged from T2 N0 - T4 N1; median follow up is 36 months. Ten pts (34%) achieved CR and 17 (59%) PR after CT. CR patients were monitored monthly. Videostroboscopy will show tumor shrinkage, normalization of mucosa, and dramatic improvement in phonatory approximation in 5 of 5 pts with true vocal cord involvement. Two of 10 CR patients have developed local recurrence, with one living and disease-free after RT. Eight pts are alive and recurrence-free. Of the entire group of 29, 6 pts have developed recurrence (6 local/regional and 1 distant). Two patients have required total laryngectomy and 3 RT. Twenty-four of 29 pts are alive and disease-free. One patient died of a second primary cancer. Conclusions: Systemic chemotherapy for intermediate stage SCC/L provides durable disease remission in some pts. This favorable early experience suggests that SCC/L is potentially curable with systemic therapy. However, treatment of larynx cancer with chemotherapy as a single modality remains highly experimental. No significant financial relationships to disclose.

Advanced larynx cancer.

Despite advances in diagnosis and treatment, the prognosis for patients with stage III-IV laryngeal cancer is not significantly different than it was four decades ago [1]. This failure to improve survival is multifactorial and is likely linked to controversy surrounding optimal treatment regimens for a heterogeneous patient and tumor population. At the root of this controversy is a lack of randomized controlled trials that compare different therapeutic options, personal and institutional treatment philosophies, and a paucity of standardized functional and quality-of-life outcome measures for specific treatment modalities. Therapeutic decision making is further complicated by the potential use of organ preservation approaches in some patients [2**, 3*, 4**]. Clearly, quality-of-life considerations are an integral part of treatment planning and a well-informed patient is necessary to achieve an optimal result. Philosophically, it is the physician's responsibility to recommend the best treatment option and to explain the other viable treatment strategies. It is our opinion that conservation laryngeal surgery represents the mainstay of treatment for patients with advanced laryngeal carcinomas, whose tumors have characteristics amenable to these approaches and who functionally can tolerate such procedures. For those patients who would likely require a total laryngectomy or who are not suitable for surgical conservation, organ preservation should be used as a primary option in a controlled setting.

Laryngeal compartmentalization after radiation therapy in a canine model

Objective: We set out to study the effects of radiation therapy on laryngeal tissue barriers in a canine model as described by Welsh. Study design: India ink was injected into 1 vocal fold on irradiated and nonirradiated canine larynges. Results: The india ink dye spread more prominently into the supraglottis of the irradiated specimens by submucosal lymphatics. Larger dye volumes simulating larger tumor bulk spread to the contralateral larynx in irradiated specimens. Conclusion: Conservation laryngeal surgery for laryngeal carcinoma is a popular method of treatment. Some surgeons advocate partial laryngectomy for radiation failures; in other instances, it is the primary modality of treatment. These findings suggest a cautious approach when planning conservative laryngeal surgery after radiation therapy failures of glottic carcinoma. (Otolaryngol Head Neck Surg 2001;125:385-92.)

Regression of laryngeal dysplasia after serial microflap excision.

There is no consensus on the ideal management of premalignant lesions of the larynx. Published reports describe the use of mucosal stripping, microsurgical techniques, CO2 laser excision and ablation, and even conservation laryngeal surgery and radiotherapy. We performed a retrospective evaluation of 43 men and 11 women who underwent serial excision of dysplastic lesions with the microflap technique between 1990 and 2001. The average age of the patients was 57.2 years; 64% had a history of cigarette smoking, and 46% a history of alcohol consumption. The lesions were located on the middle part of the left vocal fold in 65% and on the mid-portion of the right vocal fold in 66%. The patients were followed for an average of 4.4 years. Of the 20 patients with severe dysplasia or carcinoma in situ treated with the microflap technique, only 1 progressed to invasive disease. Overall, there was a reduction in the severity of dysplasia after each procedure (p = .0008). The microflap technique reliably reduced the severity of dysplastic lesions of the vocal fold and was effective in local disease control.

Descriptive anatomy of the cricoarytenoid articulation: application to articular dynamics in carcinology.

The descriptive anatomy of the cricoarytenoid articulation provides an essential foundation for understanding disorders of mobility of the larynx, especially in carcinology. Thirteen formaline-preserved anatomic specimens of the adult larynx were studied and 4 pathologic larynges with loss of mobility due to a malignant tumor. The cricoid and arytenoid articular surfaces showed major intra- and inter-individual variations, causing dynamic asymmetry at the glottic level. They were joined by a connective-elastic articular capsule bounding a cavity, characterized by a pseudo-meniscal synovial ridge and deep peripheral blind recesses, indicative of great articular mobility. The cricoarytenoid ligament shares in stabilizing the articulation. The posterior cricoarytenoid m. (abductor) and the lateral cricoarytenoid m. (adductor) have a motor innervation derived from the inferior laryngeal nerve, which forms an endolaryngeal arch with a ventral concavity, in contact with the lateral articular recess. The cricoarytenoid articulation thus appears as a diarthrosis possessing three degrees of liberty during movements of glottic abduction and adduction: an antero-posterior rocking movement, an antero-medial shift of the arytenoid on the cricoid, and a less marked axial rotation. Histological study of the cricoarytenoid articulation where mobility was reduced by carcinomatous infiltration showed that each articular component may be affected (muscles, cartilage, capsule, nerve), and that several components may be involved simultaneously to a minimal degree. The therapeutic implications are important, particularly in conservative laryngeal surgery.

방사선조사후 재발한 후두암에서 상윤상후두부분절제술의 의의

Background and Objectives: Recurrent laryngeal cancer after radiotherapy was mainly treated by total laryngectomy because of multifocal recurrent site, delayed diagnosis and inaccurate surgical margin, etc. Recently, it is possible to preserve voice function through conservative laryngeal surgery in case of radiation failed laryngeal cancer with strict application of indication. In this study, authors studied the curability of surpracricoid partial laryngectomy for radiation failed laryngeal cancers. Materials and Methods: We analyzed retrospectively 18 radiation failed laryngeal cancer patients who were treated with supracricoid partial laryngectomy with cricohyoidopiglottopexy (CHEP) or cricohyoidopexy (CHP), from May 1996 through September 2000. Their recurrent TNM stage were T1 in 7 patients, T2 in 7 patients, T3 in 3 patients, T4 in 1 patient. Evaluation of oncological and functional results were conducted. Mean follow-up period was 22 months. Results: Local recurrence occured in 1 patient (6%) and cricoid perichondritis in 5 patients (28%), pharyngocutaneous fistula in 1 patient (6%) after operation. Four patients (22%) had to be treated with completion laryngectomy. Voice function were preserved in 14 patients (78%). Conclusion: Our experience with supracricoid partial laryngectomy with CHEP or CHP suggests that this technique can be a valuable alternative to total laryngectomy in radiation failed laryngeal cancer. (J Clinical Otolaryngol 2000;11:280-285)

Partial laryngectomy for recurrent laryngeal carcinoma

From July 1975 to January 1998, 33 patients underwent partial laryngeal resection for residual or recurrent tumour after primary radical radiotherapy. Sixteen patients had T1 tumours on presentation, 14 were T2 and three were T3. Six patients underwent a supraglottic (horizontal) laryngectomy, 24 had a vertical partial laryngectomy, two had an endoscopic laser resection and one had an endoscopic laser resection followed by a vertical partial laryngectomy. The median time interval between radiotherapy and salvage surgery was 10 months (range 2-188 months). The median follow-up period was 41 months (range 12-185 months). There were five major postoperative complications (15%); two patients developed a pharyngeal fistula and three required further surgery for laryngo-tracheal stenosis. Twenty-five patients (76%) retained their larynx with satisfactory speech and swallowing. Eight patients (24%) had to be converted to a total laryngectomy, seven for recurrent disease and one for laryngeal stenosis. Of the eight patents converted, seven had normal swallowing and six developed good tracheo-oesophageal speech. Seven patients (21%) developed recurrent tumour after partial laryngectomy and were subjected to total laryngectomy; six of these seven were salvaged. Only one of the 33 patients died with recurrent tumour, giving an ultimate disease-related survival of 97%. Conservation laryngeal surgery for salvage of selected patients who fail radical radiation therapy is safe, effective, and results in reasonable preservation of laryngeal function.

Ten-year experience with cervical miniesophagostomy.

This report describes our experience with 35 patients who underwent intraoperative transcutaneous cervical miniesophagostomy (TCME) during conservation laryngeal and/or hypopharyngeal surgery. The TCME was designed to provide enteral alimentation without the need for a nasogastric tube. Nasogastric tubes may cause posterior laryngeal inflammation, granulations, muscle damage, and vocal cord immobility. Friction between nasogastric and tracheotomy tubes may result in damage to the remaining posterior larynx and may delay healing, oral feeding, and decannulation. Percutaneous endoscopic or radiologically assisted gastrostomy is a possible solution. However, it requires time, special expertise, and coordination with other specialties. In addition, immediate and delayed abdominal complications may occur. The TCME is a relatively simple and quick procedure that is performed during the primary cancer surgery by the head and neck surgeon. It requires no special equipment. It takes about 5 minutes to perform and, if done correctly with tunneling under the skin flaps, is associated with minimal or no postoperative morbidity. It is useful after supraglottic laryngectomy, partial laryngectomy, partial laryngopharyngectomy, and base of tongue resection, and in selected cases of vertical hemilaryngectomy and anterolateral laryngectomy. In the last group, we found that TCME is required if the arytenoid cartilage is removed and the posterior aspect of the larynx is disrupted. There were only minor complications related to TCME. Leakage from the miniesophagostomy did not occur, primarily because of the superior-to-inferior orientation of the tube and the long subplatysmal tunneling before esophageal entrance.

Conservation laryngeal surgery.

Conservation laryngeal surgery is an increasingly available alternative for treatment of laryngeal cancer. In addition to the traditional techniques of vertical partial laryngectomy (hemilaryngectomy) and supraglottic laryngectomy, new techniques are now in practice that extend the indications to a far greater number of patients. The carbon dioxide laser is used to resect both glottic and supraglottic cancers. This procedure is best applied to early stage I and stage II cancers. Reports indicate superior functional outcome to open surgical procedures, with shorter hospital duration, less morbidity, and equivalent survival rates. The supracricoid partial laryngectomy is becoming increasingly popular for intermediate extent tumors. This novel procedure allows resection of transglottic tumors and tumors with vocal cord paralysis while preserving the patient's speech and swallowing and avoiding a permanent tracheal stoma.

Chemotherapy combined with conservation surgery in the treatment of early larynx cancer.

In the past 20 years, strategies based on the use of platinum-based induction chemotherapy regimens have been developed in an attempt to preserve the larynx, increase local control, and improve survival in patients with advanced laryngeal cancer. In patients with early-stage laryngeal cancer, it is commonly thought that there is no role for induction chemotherapy. In this review, we support the notion that there is growing evidence available in the literature documenting the need and the role for induction chemotherapy as well as the need and the role for the use of conservation laryngeal surgery after induction chemotherapy in early-stage laryngeal cancer (T1-2N0).

Autotransplantation of the trachea: experimental evaluation of a reconstructive technique for extended hemilaryngectomy defects.

Vascularized segments of trachea were used to repair extended hemilaryngectomy defects in a rabbit model. The cervical trachea was revascularized in a first stage by a fascia flap. In a second stage, the cervical trachea was isolated and transformed into a patch that could be autotransplanted on a vascular carrier. The patches were used for the reconstruction of hemilaryngectomy defects including half of the cricoid. Two months after transplantation, the vascular and morphologic characteristics of the tracheal patches were examined with silicone dye angiography and magnetic resonance imaging. The tracheal patches showed a reliable blood supply when wrapped in vascularized fascia. The patches provided a functional reconstruction of hemicricolaryngectomy defects. It is concluded that autotransplantation of the trachea should be further explored as a potential means for extending the limits of conservation laryngeal surgery.

Preservation of the Superior Laryngeal Nerve in Supraglottic and Supracricoid Partial Laryngectomy

Conservation laryngeal surgery effectively controls laryngeal carcinoma. The success of conservation laryn- geal surgery is judged by the patient’s ability to achieve physiologic respiration, phonation, and deglutition. Some patients cannot tolerate supraglottic and supracricoid partial laryngectomy and develop sequelae such as aspi- ration pneumonia. The extent of resection in conservation laryngeal pro- cedures varies. After classic vertical partial laryngectomy, rapid resumption of deglutition is usually achieved. After supraglottic laryngectomy, swallowing therapy is initiated and feeding tube removal is usually achieved

Open Surgical Management of Early Glottic Carcinoma

Three options exist for the treatment of T1 through T3 glottic carcinomas: irradiation, transoral excision (usually with a CO2 laser) and external "conservation" laryngeal procedures. Controversy re approximately mains regarding the best therapy and, in many cases, is related to the uncertainty of tumor subclassifications not being contained in the current American Joint Committee on Cancer Union International Contra Cancer system. The evaluation of patients with early glottic carcinomas and common approaches to conservation laryngeal surgery and defect reconstructions are presented. External "conservation" approaches are preferred for T1B, T2B and early T3 glottic carcinomas.

Transcutaneous cervical miniesophagostomy.

Nasogastric tubes have been shown to cause damage to the pharyngolaryngeal complex, producing laryngeal inflammation, granulation, muscle damage, and even vocal cord immobility. The coexistence of nasogastric and tracheotomy tubes after conservation laryngeal surgery is especially harmful. The friction between these two semirigid structures may result in damage to the remaining part of the larynx. This may result in a significant delay in healing, oral feeding, and decannulation. Percutaneous endoscopic gastrostomy is a possible solution. This procedure requires time, special expertise, and cooperation between services. We present our experience with 17 transcutaneous cervical miniesophagostomies using a small-caliber feeding tube, which were performed during conservation laryngeal and/or pharyngeal surgery. The rate of minor complications was 11.7%, or 0.40 complications per 100 tube days, and no major complications were related to the procedure. Transcutaneous cervical miniesophagostomy is a simple and quick procedure that may be performed during the primary cancer surgery. It is done by the head and neck surgeon and does not require special expertise. It takes about 5 minutes to perform and, if done correctly with funneling under skin flaps, is associated with minimal or no postoperative morbidity.

Transcutaneous cervical miniesophagostomy

Nasogastric tubes have been shown to cause damage to the pharyngolaryngeal complex, producing laryngeal inflammation, granulation, muscle damage, and even vocal cord immobility. The coexistence of nasogastric and tracheotomy tubes after conservation laryngeal surgery is especially harmful. The friction between these two semirigid structures may result in damage to the remaining part of the larynx. This may result in a significant delay in healing, oral feeding, and decannulation. Percutaneous endoscopic gastrostomy is a possible solution. This procedure requires time, special expertise, and cooperation between services. We present our experience with 17 transcutaneous cervical miniesophagostomies using a small-caliber feeding tube, which were performed during conservation laryngeal and/or pharyngeal surgery. The rate of minor complications was 11.7%, or 0.40 complications per 100 tube days, and no major complications were related to the procedure. Transcutaneous cervical miniesophagostomy is a simple and quick procedure that may be performed during the primary cancer surgery. It is done by the head and neck surgeon and does not require special expertise. It takes about 5 minutes to perform and, if done correctly with tunneling under skin flaps, is associated with minimal or no postoperative morbidity. (OTOLARYNGOL HEAD NECK SURG 1995;113:387-92.)

90: Subglottic Spread of Glottic Carcinoma: The Significance of Laryngeal Size as Related to Gender

Objective: Although it is accepted that there are size differences between female and male larynges, criteria for conservation laryngeal surgery for glottic carcinoma have not specifically addressed this matter. A laryngeal cadaveric anatomic study was undertaken to determine if the current criteria for conservation laryngeal surgery for glottic carcinoma is uniformly applicable to the female larynx. The past several decades have seen an increase in tobacco use among women, accompanied by an increased incidence of laryngeal cancer, thus underlying the relevance of a study of this nature Methods: Anterior midline measurements between key landmarks of the larynges of 10 female and seven male cadavers were carried out and assessed. These measurements included the following: (1) anterior commissure to inferior border of thyroid ala distance; (2) anterior commissure to superior border of cricoid cartilage distance; and (3) anterior commissure to inferior border of cricoid cartilage distance Results: The mean anterior commissure to inferior border of thyroid ala distance was 8.3 mm (range, 6 to 10 mm) in females and 11.8 mm (range, 10 to 13 mm) in males. The mean anterior commissure to superior border of cricoid cartilage distance was 17.5 mm (range, 15 to 21 mm) in females and 21.4 mm (range, 18 to 25 mm) in males. The mean anterior commissure to inferior border of cricoid cartilage distance was 23.7 mm (range, 20 to 27 mm) in females and 30 mm (range 26 to 35 mm) in males Conclusions: The female cadaveric larynges were, on average, smaller than those of the male counterparts studied with regard to all investigated parameters. Of specific interest was the difference in the mean anterior commissure to inferior border of thyroid ala distance between female and male specimens. Classic teaching indicates that conservation laryngeal surgery for glottic carcinoma with less than 10 mm of anterior subglottic spread is oncologically sound, because tumor would theorectically be contained within the thyroid ala. Our data suggest that use of conservation laryngeal techniques in some female patients having glottic carcinoma with less than 10 mm anterior subglottic spread may be contraindicated, because spread to the level of the cricothyroid membrane (and thus extralaryngeal access) can occur well within this distance

喉頭軟骨肉腫の１症例

Chondrosarcoma of the larynx is an uncommon cartilagenous tumor. In particular, instances in the cricoid cartilage are very rare. Since these are usually of low-grade malignancy, some laryngeal chondrosarcomas can be managed successfully by conservative laryngeal surgery through laryngofissure and partial laryngectomy. However, some authors have reported the cases of recurrent tumors or death, so it can be considered that in some cases total laryngectomy would be the first choice of treatment.In this paper, we report on a 67-year-old woman with chondrosarcoma in the cricoid cartilage which required a total laryngectomy. We review 45 cases of chondrosarcoma in the cricoid and discuss the indications for total laryngectomy in accordance with the invasive limits of the tumor.

Head and neck cancer surgery.

This review presents several areas of current interest in head and neck oncology including endoscopic and conservation management of early laryngeal cancer, intraoperative radiotherapy, and microvascular reconstruction techniques. Endoscopic treatment of early laryngeal cancer using the CO2 laser has been shown to be effective in several recent studies, and improved laryngeal reconstruction techniques following conservation laryngeal surgery have resulted in improved functional results. Intraoperative radiotherapy for head and neck carcinoma has received more attention recently, with encouraging results for the treatment of advanced and recurrent skull base and head and neck tumors. New techniques of free flap reconstruction following surgery for head and neck cancer continue to result in improved rehabilitation.