Laryngeal Invasion Research Articles

Surgical management and outcomes of T4a papillary thyroid carcinoma: a single-centre study of 602 cases.

This study aimed to investigate the clinical characteristics and risk factors associated with the disease progression of T4a papillary thyroid carcinoma (PTC). In all, 602 patients (230 males; 372 females), aged 8-82 years, with T4a PTC who were admitted for initial surgery between April 2010 and September 2022 were retrospectively analysed. Tracheal invasion was observed in 271 (45.0%), oesophageal invasion in 190 (31.6%), recurrent laryngeal nerve (RLN) invasion in 516 (85.7%), and larynx invasion in 22 (3.7%) patients. The 5-year progression-free survival was 89.8%, and disease-specific survival was 96.0%, with a postoperative disease progression rate of 9.6% (54 patients) and mortality rate of 5.17% (29 patients). Disease recurrence was most likely to occur at the initial surgical site. Age ≥55 years, preoperative vocal cord paralysis, microvascular invasion, trachea invasion, and metastases to >5 cervical lymph nodes were independent risk factors for disease progression in patients with M0 stage. Male sex, preoperative vocal cord paralysis, microvascular invasion, specific pathological type, and laryngeal invasion were associated with an increased risk of disease progression for all T4a patients, while lobectomy, total thyroidectomy, tumour shaving on the RLN surface, total RLN resection, and absence of radioactive iodine therapy were not. Surgery was the primary treatment for patients with stage T4a PTC and most patients had a satisfactory prognosis. Surgeons should comprehensively evaluate each patient before deciding the surgical approach.

Automated Laryngeal Invasion Detector of Boluses in Videofluoroscopic Swallowing Study Videos Using Action Recognition-Based Networks.

We aimed to develop an automated detector that determines laryngeal invasion during swallowing. Laryngeal invasion, which causes significant clinical problems, is defined as two or more points on the penetration-aspiration scale (PAS). We applied two three-dimensional (3D) stream networks for action recognition in videofluoroscopic swallowing study (VFSS) videos. To detect laryngeal invasion (PAS 2 or higher scores) in VFSS videos, we employed two 3D stream networks for action recognition. To establish the robustness of our model, we compared its performance with those of various current image classification-based architectures. The proposed model achieved an accuracy of 92.10%. Precision, recall, and F1 scores for detecting laryngeal invasion (≥PAS 2) in VFSS videos were 0.9470 each. The accuracy of our model in identifying laryngeal invasion surpassed that of other updated image classification models (60.58% for ResNet101, 60.19% for Swin-Transformer, 63.33% for EfficientNet-B2, and 31.17% for HRNet-W32). Our model is the first automated detector of laryngeal invasion in VFSS videos based on video action recognition networks. Considering its high and balanced performance, it may serve as an effective screening tool before clinicians review VFSS videos, ultimately reducing the burden on clinicians.

A preliminary deep learning study on automatic segmentation of contrast-enhanced bolus in videofluorography of swallowing

Although videofluorography (VFG) is an effective tool for evaluating swallowing functions, its accurate evaluation requires considerable time and effort. This study aimed to create a deep learning model for automated bolus segmentation on VFG images of patients with healthy swallowing and dysphagia using the artificial intelligence deep learning segmentation method, and to assess the performance of the method. VFG images of 72 swallowing of 12 patients were continuously converted into 15 static images per second. In total, 3910 images were arbitrarily assigned to the training, validation, test 1, and test 2 datasets. In the training and validation datasets, images of colored bolus areas were prepared, along with original images. Using a U-Net neural network, a trained model was created after 500 epochs of training. The test datasets were applied to the trained model, and the performances of automatic segmentation (Jaccard index, Sørensen–Dice coefficient, and sensitivity) were calculated. All performance values for the segmentation of the test 1 and 2 datasets were high, exceeding 0.9. Using an artificial intelligence deep learning segmentation method, we automatically segmented the bolus areas on VFG images; our method exhibited high performance. This model also allowed assessment of aspiration and laryngeal invasion.

Functional Outcomes and Survival After Total Glossectomy With Laryngectomy: A Systematic Review

Total glossectomy with laryngectomy (TGL) is an invasive and major operation known to carry high morbidity and mortality risks. Thus, it is reserved only for select cases of advanced tongue cancer with extensive laryngeal invasion that is causing significant detriment to a patient's quality of life. Use of this technique is controversial as there is a significant impact to patients from disfigurement, and loss of functional speech and swallow, and the long-term functional outcomes have traditionally been thought to be poor.

Risk Stratification of Dysphagia After Surgical Treatment of Hypopharyngeal Cancer.

ObjectiveHypopharyngeal cancer is managed by either surgical resection or radiation therapy-based treatment. In choosing the treatment modality, the patient’s swallowing function should be considered to achieve optimal treatment outcomes. This study aimed to stratify the risk factors predictive of postoperative dysphagia in hypopharyngeal cancer.Study DesignRetrospective study.SettingTertiary referral center.MethodsWe enrolled 100 patients who were diagnosed with hypopharyngeal cancer and underwent curative surgery between January 2010 and December 2019, and retrospectively reviewed their medical records.ResultsPostoperative dysphagia occurred in 29 patients (29%) who required a tracheostomy tube or percutaneous gastrostomy tube for feeding or preventing aspiration; additionally, the overall survival rate was lower in those patients than in those without dysphagia. The univariate analysis revealed that postoperative dysphagia was associated with clinical T stage (p = 0.016), N stage (p = 0.002), and surgical resection extent of the larynx and pharynx (p < 0.001). Patients who underwent total laryngectomy with total/partial pharyngectomy were more likely to have dysphagia than those in the larynx-preserving pharyngectomy groups (odds ratio [OR] = 3.208, 95% confidence interval [CI] 1.283–8.024, p = 0.011). Concerning the posterior pharyngeal wall (PPW), which has an important role in swallowing, patients who underwent resection of ≥1/2 of the PPW were more likely to have dysphagia (OR = 7.467, 95% CI 1.799–30.994, p = 0.003).ConclusionsSurgical resection extent was proportionally associated with dysphagia in hypopharyngeal cancer patients. Patients with smaller lesions but no laryngeal invasion had better postoperative swallowing function than patients with larger lesions or laryngeal involved lesions. Preserving the larynx and hypopharyngeal mucosa (especially the PPW) as much as possible can help preserve postoperative swallowing function.

Using RNA sequencing to identify a putative lncRNA-associated ceRNA network in laryngeal squamous cell carcinoma

ABSTRACT Accumulating evidence indicates that lncRNAs can interact with miRNAs to regulate target mRNAs through competitive interactions. However, this mechanism remains largely unexplored in laryngeal squamous cell carcinoma (LSCC). In this study, transcriptome-wide RNA sequencing was performed on 3 pairs of LSCC tissues and adjacent normal tissues to investigate the expression profiles of lncRNAs, miRNAs and mRNAs, with differential expression of 171 lncRNAs, 36 miRNAs and 1709 mRNAs detected. Seven lncRNAs, eight mRNAs and three miRNAs were identified to be dysregulated in patients’ tissues by using qRT-PCR. GO and KEGG pathway enrichment analyses were performed to elucidate the potential functions of these differentially expressed genes in LSCC. Subsequently, a ceRNA (lncRNA-miRNA-mRNA) network including 4631 ceRNA pairs was constructed based on predicted miRNAs shared by lncRNAs and mRNAs. Cis- and transregulatory lncRNAs were analysed by bioinformatics-based methods. Importantly, mRNA-related ceRNA networks (mRCNs) were further obtained based on potential cancer-related coding genes. Coexpression between lncRNAs and downstream mRNAs was used as a criterion for the validation of mRCNs, with the ZNF561-AS1-miR217-WNT5A and SATB1-AS1-miR1299-SAV1/CCNG2/SH3 KBP1/JADE1/HIPK2 ceRNA regulatory interactions determined, followed by experimental validation after siRNA transfection. Moreover, ceRNA activity analysis revealed that different activities of ceRNA modules existing in specific pathological environments may contribute to the tumorigenesis of LSCC. Consistently, both downregulated SATB1-AS1 and ZNF561-AS1 significantly promoted laryngeal cancer cell migration and invasion, indicating their important roles in LSCC via a ceRNA regulatory mechanism. Taken together, the results of this investigation uncovered and systemically characterized a lncRNA-related ceRNA regulatory network that may be valuable for the diagnosis and treatment of LSCC.

Treatment and Outcomes in pT4 Well-Differentiated Thyroid Carcinoma

Locally advanced, pT4 well differentiated thyroid carcinoma is a relatively rare entity and the benefit of external beam radiotherapy (EBRT) is unclear. The purpose of this study is to evaluate locoregional control (LRC) and cancer specific survival (CSS) of patients with pT4 well differentiated thyroid carcinoma in the largest retrospective cohort to date. Electronic records of patients with pT4 well-differentiated thyroid carcinoma treated at our institution from 2001 to 2013 were reviewed. Log-rank test and multivariable Cox regression were used to establish factors impacting locoregional control and cancer specific survival. A total of 232 patients were treated during this time period. The most common histologies were papillary carcinoma (n=192) and follicular carcinoma (n=11). The median age was 58 and 61% were female. Median follow up time was 11 years. The median tumor size was 3.1cm (interquartile range: 2.0-5.0cm), 60% had multifocal disease, 33% lymphovascular invasion, 9% perineural invasion and 64% had node positive disease. Local invasion into the strap muscles was seen in 51%, trachea 33%, larynx 4%, pharynx 3%, and recurrent laryngeal nerve 1%. 22% patients had an R0 resection, 55% R1 and 23% R2. 92% patients received adjuvant radioactive iodine therapy. A total of 88 patients received external beam radiotherapy with a median dose of 60Gy. There were 7 acute grade 3 toxicities (3 dysphagia, 2 nausea, and 2 pain) and 7 late grade 3 toxicities in the cohort (2 dysphagia, 3 esophageal stricture, 1 pain, 1 laryngeal stenosis). There were no grade 4 toxicities observed. Ten year LRC was 65%, CSS was 85%, and OS was 75%. On multivariate analysis, older age (p=0.02, HR 1.02, 95% CI 1.0-1.04), larynx invasion (p=0.05, HR 3.32, 95% CI 1.0-11.0) and larger tumor size (p=0.01, HR 1.17, 95% CI 1.04-1.32) were associated with worse LRC. Older age (p<0.001, HR 1.10, 95% 1.06-1.15), lymphovascular invasion (p=0.002, HR 3.3, 95% 1.5-7.2), perineural invasion (p=0.02, HR 2.9, 95% 1.19-7.48), and tracheal invasion (p=0.009, HR 2.7, 95% CI 1.3-5.5) were associated with worse CSS. Adjuvant RT was not associated with improved LRC and CSS when the entire cohort was assessed. However, for patients with microscopic or macroscopic residual disease (R1 and R2 resection), adjuvant radiotherapy was associated with improved LRC on multivariable analysis (p=0.02, HR 0.45, 95% CI 0.23-0.90). Despite locally advanced disease; 10 year CSS was 85% in this cohort of patients with pT4 DTC. Adjuvant radiotherapy improved LRC for patients with R1 and R2 resections. There was a low rate of toxicity from EBRT for the cohort.

Down-regulation of SOX18 inhibits laryngeal carcinoma cell proliferation, migration, and invasion through JAK2/STAT3 signaling.

Laryngeal carcinoma is one of the most common malignant tumors of the head, neck, and respiratory tract. The aim of the present study is to explore the biological function of SRY-related HMG-box 18 (SOX18) in laryngeal carcinoma cells and study the molecular mechanism involved. Initial findings indicate that the expression of SOX18 was increased in laryngeal carcinoma cell lines and tissues. The effect of SOX18 on laryngeal carcinoma cell proliferation, cell cycle, apoptosis, invasion, and migration was also identified. The results indicated that down-regulation of SOX18 significantly inhibited cell proliferation, migration, and invasion, and induced cell-cycle arrest in G0/G1 phase and apoptosis of laryngeal carcinoma cells. However, overexpression of SOX18 promoted cell proliferation, invasion, and migration, and inhibited cell apoptosis. The expression of cyclin D1, active-caspase-3, N-cadherin, MTA1, MMP-2, and MMP-7 was also regulated by the overexpression of siSOX18 or SOX18. In addition, it was found that SOX18 could also accelerate the phosphorylation of JAK2/STAT3 signaling in laryngeal carcinoma cells. Furthermore, our study indicated that SOX18 could stimulate cell proliferation, migration, and invasion of laryngeal carcinoma cells via regulation of JAK2/STAT3 signaling, which could provide a new strategy for laryngeal carcinoma diagnosis and molecular therapies.

The role of laryngectomy in locally advanced thyroid carcinoma. Review of 16 cases

Locally advanced disease with larynx invasion is a challenge to the surgeon, but laryngectomy is almost never necessary in thyroid carcinoma. The aim of this study was to review the clinical outcomes of patients with locally advanced thyroid carcinoma invading the larynx who underwent laryngectomy. A case series of patients treated in a tertiary care hospital was reviewed. Data about the type of operation, method of reconstruction, complications and overall survival of 16 patients operated on between 2002 and 2015 with larynx invasion is presented. There were 10 females. The mean age was 63 ± 8.8 years. Besides total thyroidectomy and neck dissection, four patients underwent total pharyngolaryngectomy, 11 total laryngectomy and one hemi-laryngectomy. Reconstruction was made with regional flaps in 10 patients (7 pectoral/Bakamjian flaps and 3 gastric pull-through procedures) and a jejunum free flap in one patient. Two patients needed carotid artery reconstruction. Five tumours were classic (conventional) papillary carcinoma variants, while the others were aggressive histological varieties (insular, tall cell, sclerosing). The mean tumour size was 4.3 ± 1.6 cm. All tumours had lymphovascular invasion and 12 had positive lymph nodes. Concomitantly, oesophageal/hypopharyngeal invasion was present in 7 cases and invasion of carotid vessels in 2 cases. There were two postoperative deaths and two anastomotic leaks that were treated conservatively. The mean overall survival was 31 ± 33 months (median 27.6 months, range 0-120). Laryngectomy is an alternative surgical procedure to control selected cases of advanced thyroid carcinoma that offers good local control and long term survival.

Window Resection for Intraluminal Cricotracheal Invasion by Papillary Thyroid Carcinoma.

Invasion of the upper aerodigestive tract by papillary thyroid carcinoma (PTC) affects both prognosis and quality of life. We assessed the efficacy of window resection for patients with intraluminal cricotracheal invasion. Clinical data were retrospectively reviewed for all patients with PTC undergoing surgery at our institution during 1981-2009. Seventy-six patients with intraluminal cricotracheal invasion were enrolled, including 34 relapsing patients. The 10-year disease-specific survival rate of 42 patients with intraluminal invasion who underwent initial surgery was 60.8%. The lesion was located on the laryngo-trachea in 3 (4%) of 12 patients with locoregional recurrence. No major surgical complications were associated with cricotracheal resection. Stomal closure was achieved in 30 of 76 patients (39%). Twelve patients (16%) had a permanent stoma that was directly related to cricotracheal invasion. Their stomas had been caused by large cricotracheal defects with greater than or equal to 50% circumferential resection of the trachea. Sixty-seven patients (88%) had PTC invasion into other aerodigestive structures, including the recurrent laryngeal nerve (n=54), esophagus (n=38), and thyroid cartilage or intraluminal invasion of the larynx (laryngeal invasion n=23). Multivariate analysis showed that cricotracheal invasion accompanied by recurrent laryngeal nerve invasion was predictive of permanent stoma (odds ratio 0.32; 95% CI 0.107-0.945; p=0.039). Window resection appears to be an effective treatment option for patients with intraluminal cricotracheal invasion. However, this surgical technique may be inappropriate for the treatment of large cricotracheal defects without a supportive hard structure.

Reconstruction of defect after resection of hypopharyngeal and cervical esophageal cancer by multiple tissue flaps

To explore a new method for the reconstruction of defect after resection of hypopharyngeal and cervical esophageal cancer using pulled-up stomach combined with free jejunal flap or lanryngotracheal flap if pulled-up stomach can not reach the level of oral pharynx for ananstamosis. From June 2010 to June 2014, 56 cases of hypopharyngeal or cervical esophageal cancer were treated with pharyngogastric anastamosis, in 5 cases of them, because the length of pulled-up stomach was limited and could not reach oral pharynx, free jejunal flap was used in 2 cases with laryngeal invasion and laryngotracheal flap was used in 3 cases without laryngeal invasion to reconstruct the defect between oral pharynx and stomach. Pharyngeal fistula occurred in 1 case with laryngotracheal flap reconstruction, but healed after 2 weeks of wound dressing. Other 4 cases had oral liquid diet two weeks after surgery and did not occur any complications such as infection or pharyngeal fistula. Follow-up showed 1 case died from mediastinal and lung metastases after 3 years, 1 case had cervical lymph recurrence after 2 years and still survived, and other 3 cases were tumor free survival for 28, 37, and 56 months respectively. The defect after resection of hypopharyngeal and esophageal cancer can be reconstructed with pulled-up stomach combined with free jejunal flap or lanryngotracheal flap if pulled-up stomach can not reach the level of oral pharynx for ananstamosis.

Cartilage invasion patterns in laryngeal cancer.

The cartilaginous invasion determines the T and is one of the most common sources of mistake in tumor staging. Also it is of great importance when planning any therapeutic alternative. In the latest revision of the TNM classification a clear distinction is made between infiltration of cartilage without going through it, considered a T3 recently and that would be a T4 according to the previous classification, and those going through the cartilage, classified as T4a. While this classification makes the difference in depth of infiltration, it does not emphasize the extent of invasion. This paper provides a detailed description of the laryngeal cartilage tumor infiltration by whole organ serial section in which the invasion is considered both horizontal (transcartilaginous) and vertical (extent of invasion) and establishing patterns of three-dimensional infiltration of the cartilage. This is a cross-sectional study of prevalence. 275 records of patients treated for laryngeal squamous cell carcinoma between 1995 and 2000 were reviewed. The pathological processing of laryngectomy surgical specimens was performed following the method of whole organ serial section described by G. F. Tucker. The following patterns of cartilaginous infiltration were defined: (1) transcartilaginous infiltration; (2a) partial focal infiltration of the cartilage: infiltration not going through the cartilage but occupying one third or less of its extent; (2b) partial extensive infiltration of the cartilage: infiltration occupying two thirds or more of its length and (3) no cartilage infiltration: tumor in contact with the cartilage (paraglottic space) but without affecting it. 161 patients met the inclusion criteria. The most frequent tumor location was supraglottic (58 cases) followed by glottic (47). 109 patients (67.7%) were treated with total laryngectomy. Partial surgical techniques were performed in the remaining cases. TNM tumor staging was performed according to the results of pathological study (pTNM). 72.06% (116) were classified as advanced laryngeal tumors (pT3 and pT4). 46% of patients showed some extent of laryngeal cartilage infiltration (thyroid, cricoid, arytenoids, epiglottis). The cartilage most frequently infiltrated was the thyroid in 48 patients (29.8%) and when it is affected, in most cases (66.7%), the infiltration is transcartilaginous. The next most common pattern is partial focal infiltration (27%). In the cricoid cartilage, the most common pattern of infiltration is focal partial infiltration (52.6%). Of the 19 cases with infiltration of the cricoid, there are 12 cases with extra laryngeal invasion through a cricothyroid membrane perforation. The study of laryngeal cancer by laryngeal whole serial section has been proved to be very useful in offering a high precision pTNM staging and a detailed description of the infiltration of cartilage. We have seen that when the thyroid cartilage is infiltrated the tumor often passes through the cartilage. However, there are cases where the tumor is extremely aggressive, being very widespread in cartilage thickness without actually crossing it. The isolated infiltration of the cricoid cartilage is exceptional.

Surgical management of laryngeal invasion by papillary thyroid carcinoma: a retrospective analysis.

Papillary thyroid carcinoma (PTC) has an excellent prognosis. Although rare, PTC invasion into the upper aerodigestive tract can adversely affect patient prognosis and quality of life. This study investigated the impact of tumor excision on the prognosis and postoperative status of patients with PTC invasion of the larynx. Data on PTC patients who underwent surgery at the author's institution between April 1981 and March 2010 were retrospectively reviewed, and 55 patients with thyroid cartilage invasion were enrolled. Curative resection was performed for all patients, and laryngeal function was preserved or reconstructed when possible. Of the 55 patients, 40 and 15 patients had superficial and intraluminal invasion of the larynx, respectively. The 10-year disease-specific survival rates were 81.0% and 61.4% in patients who underwent surgery for superficial and intraluminal invasion of the larynx, respectively. Only two patients (3.6%) had an isolated locoregional recurrence in the larynx. Four patients (7.3%) underwent total laryngectomy during the initial surgery or surgery for laryngeal recurrence. Permanent stoma remained in 26 patients (47%): 14 with laryngeal invasion, and 12 with invasion of other aerodigestive structures. The number of invaded aerodigestive structures including the larynx was correlated with the presence of permanent stoma. In many patients, PTC invasion of the larynx remained at the thyroid cartilage or paraglottic space. Most patients did not require total laryngectomy. Good locoregional control was achieved with surgical tumor excision in patients with laryngeal invasion. Distant metastases were the major cause of death in patients with PTC invasion of the larynx.

Prognosis of Papillary Thyroid Carcinoma with Local Invasion

The aim of this study was to detect prognostic factors in patients with locally advanced papillary thyroid carcinoma. The study included 72 patients (T4a/T4b 72/0, N0/N1a/N1b 25/15/32, M0/M1 68/4, mean follow-up 8.1 4.4 years) who underwent initial surgical treatment at Osaka Red Cross Hospital between April 1993 and April 2011. Eleven patients died of PTC, 3 patients with recurrence died of unrelated disease and 10 patients are alive with recurrence. The overall 5-year survival rate was 88.3%, and the 10-year survival rate was 73.4%. The disease-specific 5-year survival rate was 91.4%, and the 10-year survival rate was 88.6%. The 5-year local control rate was 94.1%, and the 10-year local control rate was 85.4%. Patients with distant metastasis (M1), tracheal invasion and/or multiple organs invasion showed a significantly worse disease-specific survival rate based on a univariate analysis, which also revealed that tracheal invasion, laryngeal invasion, esophageal invasion and multiple organs invasion were risk factors linked to the development of distant metastasis during follow-up (recurrence as distant metastasis). The following were found to be clinically significant risk factors, based on the multivariate analysis among tracheal invasion, laryngeal invasion, esophageal invasion and recurrent laryngeal nerve invasion : Tracheal invasion was a risk factor for disease-specific survival, and tracheal invasion and laryngeal invasion were risk factors for recurrence as distant metastasis. In this study, distant metastasis, multiple organs invasion, tracheal invasion and/or laryngeal invasion were shown to be higher risk factors.

Xenogeneic acellular dermal matrix in combination with pectoralis major myocutaneous flap reconstructs hypopharynx and cervical esophagus.

The aim of this study was to explore xenogeneic acellular dermal matrix (ADM) in combination with pectoralis major myocutaneous flap in hypopharynx and cervical esophagus reconstruction. A total of five patients were treated with this surgical method to reconstruct hypopharynx and cervical esophagus in Second Xiangya Hospital between January 2012 and April 2013. Four of them had hypopharyngeal carcinoma with laryngeal and cervical esophageal invasion, while the fifth patient with hypopharyngeal cancer had developed scars and atresia after postoperative radiotherapy. The defect length after hypopharyngeal and cervical esophageal resection was 6-8 cm, and was repaired by a combination of ADM and pectoralis major myocutaneous flap by our team. Interestingly, the four patients had primary healing and regained their eating function about 2-3 weeks after surgery, the fifth individual suffered from pharyngeal fistula, but recovered after dressing change about 2 months. Postoperative esophageal barium meals revealed that the pharynx and esophagus were unobstructed in all five patients. Xenogeneic ADM in combination with pectoralis major myocutaneous flap for hypopharynx and cervical esophagus reconstruction is a simple, safe and effective method with fewer complications. Nevertheless, according to the defect length of the cervical esophagus, the patients need to strictly follow the medical advice.

Management of invasive well‐differentiated thyroid cancer: An American head and neck society consensus statement: AHNS consensus statement

Invasive differentiated thyroid cancer (DTC) is relatively frequent, yet there is a paucity of specific guidelines devoted to its management. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to provide clinical consensus statements based on review of the literature, synthesized with the expert opinion of the group. An expert panel, selected from membership of the AHNS, constructed the manuscript and recommendations for management of DTC with invasion of recurrent laryngeal nerve, trachea, esophagus, larynx, and major vessels based on current best evidence. A Modified Delphi survey was then constructed by another expert panelist utilizing 9 anchor points, 1 = strongly disagree to 9 = strongly agree. Results of the survey were utilized to determine which statements achieved consensus, near-consensus, or non-consensus. After endorsement by the AHNS Endocrine Committee and Quality of Care Committee, it received final approval from the AHNS Council.

Classification of aerodigestive tract invasion from thyroid cancer

Widely invasive extrathyroidal thyroid cancer invading the aerodigestive tract (ADT) including larynx, trachea, hypopharynx, and/or esophagus occurs in 1-8% of patients with thyroid cancer and is classified as T4a (current UICC/AJCC system). The T4a stage is associated with impaired tumor-free survival and increased disease-specific mortality. Concerning prognosis and outcome, further subdivisions of the T4a stage, however, have not been made so far. This study is based on a systematic review of the relevant literature in the PubMed database. Retrospective studies suggest a better outcome in patients with invasion of the trachea or the esophagus when compared to laryngeal invasion. Regarding surgical strategies, ADT invasion can be classified based on a three-dimensional assessment determining surgical resection options. Regardless of the invaded structure, tumor infiltration of the ADT can be subdivided into superficial, deep extraluminal, and intraluminal invasion. In contrast to superficial ADT invasion, allowing tangential incomplete wall resection (shaving/extramucosal esophagus resection), deeper wall and intraluminal invasions require complete wall resection (either window or sleeve). Based on the Dralle classification (types 1-6), particularly airway invasion, can be further classified according to the vertical and horizontal extents of tumor invasion. The Dralle classification can be considered as a reliable subdivision system evaluated regarding surgical options as well as oncological outcome. However, further studies determining the prognostic impact of this technically oriented classification system are required.

Cricotracheal resection for laryngeal invasion by thyroid carcinoma: our experience

Invasion of the laryngeal framework by thyroid carcinoma requires specific surgical techniques and carries a higher rate of complications that deserve to be highlighted. We reviewed our data from 1995 to 2012 and found six patients with laryngotracheal invasion by thyroid carcinoma. All underwent total thyroidectomy and single-stage cricotracheal resection, plus anterolateral neck dissection. Three had airway obstruction that necessitated prior endoscopic debulking. None of the patients needed a tracheotomy. There were four cases of papillary carcinoma, and two cases of undifferentiated carcinoma. One patient died of complications of the procedure (anastomotic dehiscence and tracheo-innominate artery fistula). Another died 2 months after the procedure from local recurrence and aspiration pneumonia. One case presented recurrence at 15 months, which was managed by re-excision and adjuvant radiotherapy; after 26 months of follow-up, he has no evidence of locoregional recurrence. The three other patients are alive without evidence of disease at 6, 18 and 41 months, respectively. Cricotracheal resection for subglottic invasion by thyroid carcinoma is an effective procedure, but carries significant risks of complications. This could be attributed to the devascularisation of the tracheal wall due to the simultaneous neck dissection, sacrifice of the strap muscles or of a patch of oesophageal muscle layer. We advocate a sternocleidomastoid flap to cover the anastomosis. Cricotracheal resection for subglottic invasion can be curative with good functional outcomes, even for the advanced stages of thyroid cancer. Endoscopic debulking of the airway prior to the procedure avoids tracheotomy.

Reconstruction of Pharyngeal Defects with a Submental Island Flap after Hypopharyngeal Carcinoma Ablation

Purpose: This study aimed to evaluate the oncologic and functional results of pharyngeal defect reconstruction using a submental island flap in hypopharyngeal cancer patients. Methods: Functional and oncologic results were assessed in 14 patients based on a retrospective chart review. Speech function grading was as follows: 1 = excellent (>70% intelligibility); 2 = good (40–70% intelligibility), and 3 = poor (<40% intelligibility). Swallowing function score was stratified as 1 = full diet (excellent), 2 = soft diet (excellent-good), 3 = liquid diet (good), 4 = combined oral and gastric tube (good-poor), and 5 = gastric tube-dependent (poor). Results: All flaps survived well. Salivary fistula with infection was found in 1 patient and treated conservatively. The mean length of hospitalization, and speech and swallowing scores according to laryngeal invasion in 11 patients after partial pharyngectomy were 21.63 ± 4.31 versus 11 ± 2.00 (p = 0.003), 2.38 ± 0.5 versus 1.67 ± 1.16 (p = 0.18) and 3.88 ± 0.84 versus 3.33 ± 1.53 (p = 0.46), respectively. Speech and swallowing returned to good-excellent in 63.6% and good in 45.5% of patients after surgery. Conclusions: The submental island flap is reliable for reconstructing laryngopharyngeal defects after ablation of hypopharyngeal cancer. Speech and swallowing are restored to good function in half of the patients. Laryngeal involvement of the cancer is predictive of longer hospitalization.

Surgical treatment of recurrent parathyroid carcinoma with invasion of the upper aerodigestive tract

To evaluate the factors contributed to the recurrence of parathyroid carcinoma with the invasion of the upper aerodigestive tract and the outcomes of reoperation. Six cases reviewed, in which the age ranged from 32 to 79 years old. The initial diagnoses and surgical procedures, the sites and surgical treatment of the recurrent disease, and the chemical markers, such as parathyroid hormone (PTH) and serum calcium, were retrospectively studied. The preoperative PTH levels ranged from 860 to 2830 ng/L. In 4 patients the recurrence diseases were founded in the tracheoesophageal groove, of them one with invasion of the larynx only and one with invasion of the larynx and pharynx in addition to the trachea and esophagus involvement. Selective neck dissection for level II, III, IV and VI was taken in all cases in addition to the removal of the local recurrent diseases. Recurrent laryngeal nerves were so badly embedded in tumor tissue that they were intentionally resected in 4 patients although they were functionally normal before operation. Prophylactic tracheostomy was carried out in 5 cases. PTH level dropped more than 70% of that prior the operation at 10 min after the removal of the tumor-bearing tissues and to normal range within the first 2 hours postoperatively, and hypocalcemia disappeared in 2 days postoperatively. All cases experienced significant improvement in symptoms and signs in the first three days postoperatively. PTH and serum calcium levels were within normal range in 4 cases during the follow-up of 11 to 40 months, while hyperparathyroidism was encountered 8 and 11 months postoperatively in other 2 cases, respectively. Esophageal fistula, chylous fistula and dehiscence of sternotomy developed in 3 cases separately. Of 5 patients with tracheostomy, the tracheostomy tubes were removed two weeks in 4 cases and six weeks in the other one after operation. Recurrent parathyroid carcinoma even with invasion of the upper aerodigestive tract still has promising surgical outcomes. Both the precise localization of the recurrent diseases and the intraoperative PTH assay are importance to the successful treatment of these diseases.