Surgery For Laryngeal Cancer Research Articles

Swallowing Function Outcomes Following Nonsurgical Therapy for Advanced-Stage Laryngeal Carcinoma

The purposes of this study were to (1) evaluate swallowing function using both subjective and objective measures in patients treated nonsurgically for stages III and IV laryngeal squamous cell carcinoma, (2) assess the effect of time from treatment completion on swallowing function, and (3) assess sequelae associated with modality of treatment. To achieve these objectives, a retrospective study of 14 patients was conducted. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed and evaluated by three independent judges for seven functional criteria: standing secretions, valleculae spillage, valleculae residue, postcricoid residue, laryngeal penetration, aspiration, and cough. Patient interviews were performed to establish patient perception of swallowing and his/her current posttreatment diet. Results revealed that each patient exhibited swallowing abnormalities in at least one of the seven objective functional categories studied. Ten patients suffered from variable degrees of dysphagia, ranging from mild to severe, on all measures. No significant differences were noted between those patients with less than or greater than 12 months posttreatment. Common treatment sequelae included PEG tube placement for nutritional supplementation, tracheostomy placement for airway security and/or pulmonary toilet, repeated episodes of aspiration pneumonia requiring hospital admission, and radiation-induced oropharyngeal stricture. Further studies using subjective and objective swallowing function measures for patients treated with alternative chemoradiation regimens versus surgery (with or without adjuvant therapies) for advanced stage laryngeal cancer are needed.

Carotid artery pseudoaneurysm as a rare sequela of surgery for laryngeal cancer

Formation of carotid artery pseudoaneurysm is uncommon after intensive treatment for head and neck cancer. We encountered a case of postoperative formation of pseudoaneurysm at the left carotid bifurcation in a diabetic man. The risk factors for carotid artery pseudoaneurysm in the patient included diabetes mellitus, previous radiotherapy to the neck, neck dissection, and postoperative Staphylococcus aureus infection secondary to accidental pharyngocutaneous fistula. We successfully obliterated this pseudoaneurysm using a Smart stent and detachable coils without neurological deficits. The possibility of vascular injury after treatment for head and neck cancer must be considered, especially in patients with risk factors for it due to previous treatment.

Stress hormone changes in general anesthesia of long duration: isoflurane–nitrous oxide vs sevoflurane–nitrous oxide anesthesia

Study Objective There are few comparative studies of stress hormone changes during general anesthesia with long duration between isoflurane–nitrous oxide and sevoflurane–nitrous oxide anesthesia. We investigated perioperative changes of stress hormone in these two anesthetic methods with duration of more than 10 hours. Design Prospective study. Setting Operating room and high care unit of a university hospital. Patients Twenty patients with ASA physical status I or II for surgery for laryngeal or pharyngeal cancer with expected duration of more than 10 hours. Interventions Anesthesia was induced with midazolam, thiopental, and vecuronium and was maintained with sevoflurane (sevoflurane group) or isoflurane (isoflurane group) with nitrous oxide 4 L/min in oxygen 2 L/min. Measurements and Main Results Plasma concentrations of epinephrine, norepinephrine, cortisol, adrenocorticotropic hormone, and anti-diuretic hormone (ADH); serum concentrations of glucagon and insulin; and blood glucose concentration were measured before inhalation of anesthetics, after 5 and 10 hours, and at 1, 6, and 12 hours after the end of inhalation. Epinephrine and norepinephrine concentrations increased continuously during and after surgery in the isoflurane group whereas it increased only after surgery in the sevoflurane group. Both concentrations were higher in the isoflurane group during anesthesia. Cortisol increased continuously whereas adrenocorticotropic hormone increased only during surgery. Anti-diuretic hormone increased with its peak during surgery and the isoflurane group had significantly higher values than the sevoflurane group. Glucose increased both during and after surgery, insulin increased only after surgery, and glucagon decreased during surgery in both groups. Conclusions In inhalation anesthesia with the duration of more than 10 hours, isoflurane–nitrous oxide and sevoflurane–nitrous oxide had the same effects on stress hormone changes except for epinephrine, norepinephrine, and ADH. Epinephrine, norepinephrine, and ADH concentrations were higher in isoflurane–nitrous oxide anesthesia.

The evolving role of surgery in the management of head and neck tumors

This paper reviews recent surgical contributions to the multidisciplinary approach to head and neck cancer treatment as well as published data on pertinent questions in the field. The role of surgery in the strategy of organ preservation via chemoradiation, including treatments of complications and locoregional recurrences, such as when N1-N3 necks should be operated on and the role of CT and positron emission tomography (PET) scanning. Also covered are the role of sentinel lymph node biopsy for the detection of occult micrometastases in the N0 neck and the value of fluorodeoxyglucose PET scanning combined with the former. Transoral laser surgery for tumors of the larynx or of the hypopharynx is discussed, as is a new technique of reconstruction involving the anterolateral thigh free flap. Also included are quality of swallowing after resections and reconstruction of the oral cavity and orpharyngeal tumors. Surgery must define its role in the multidisciplinary treatment of advanced cancers, which currently often favors (chemo)radiotherapy protocols. Organ sparing by transoral laser surgery for laryngeal and hypopharyngeal cancer has established itself within our armamentarium and its exact role will be further refined. Larger and well-executed studies on sentinel lymph node biopsy in the clinically negative neck are needed before this procedure can be implemented in our routines. The latest addition, the anterolateral thigh flap, to further decrease patients' morbidity is unlikely to completely replace the currently favored radial forearm flap in soft tissue replacement of the head and neck. Outcome analysis, including swallowing, is a major step that surgeons should further investigate.

Cost Comparison of Surgery vs Organ Preservation for Laryngeal Cancer

To perform a cost minimization analysis of total laryngectomy with postoperative radiotherapy vs induction chemotherapy with subsequent radiotherapy in patients with advanced (stage III or IV) squamous cell carcinoma of the larynx. Decision-analysis model using data from peer-reviewed trials, case series, meta-analyses, and Medicare diagnosis related group reimbursement rates. A hypothetical cohort of patients with stage III or IV laryngeal cancer. The perspective is that of a health care payer. The hypothetical patient cohort could receive (1) surgery (total laryngectomy) with postoperative radiotherapy or (2) induction chemotherapy (fluorouracil and cisplatin) with radiotherapy followed by salvage surgery for patients failing to respond to chemotherapy. Overall difference in direct medical costs in 2003 US dollars between the 2 treatment arms from initiation to completion of treatment. In the baseline analysis, the direct medical costs for the surgical arm were 30,138 US dollars per patient. For the organ preservation arm, the direct medical costs were 33,052 US dollars per patient. The finding that the surgical arm costs were lower was robust to all sensitivity analyses except for the extreme low estimate for the cost of chemotherapy. Our results suggest that total laryngectomy with postoperative radiotherapy costs nearly 3000 US dollars less than organ preservation treatment for advanced laryngeal cancer. Given that survival appears equivalent between the 2 modalities, cost consideration and patient preference may be important factors in decision making for the treatment of advanced laryngeal cancer.

Voice following laryngeal cancer surgery

Voice following laryngeal cancer surgery

Laser surgery for T1 laryngeal cancer

We reported the result of laser surgery for T1 laryngeal cancer and discussed its effectiveness.Subjects were 84 cases who had been treated for T1 laryngeal cancer by laser surgery at Otolaryngology of National Defense Medical College Hospital. There were 2 supraglottic cases, 73 glottic, and 9 recurrent glottic after irradiation.Out of 47 cases with T1a glottic cancer, 38 cases were treated by laser alone and 9 were by laser and irradiation. One of 38 cases by laser alone resulted in local recurrence.Out of 26 with T1b, 14 were treated by laser alone and 12 were by laser and irradiation. One of 14 cases of laser resulted in local recurrence, and as for 12 cases of laser and irradiation, one resulted in local recurrence and two resulted in failure.We succeeded in treating two cases with supraglottic cancer by laser alone. All recurrent glottic cancer cases were treated by laser alone. We failed in one of five rT1a cases. Two of four rT1b resulted in failure and one resulted in local recurrence.In case of failure and recurrence, total laryngectomy was administered. None died of cancer. Laser surgery for T1 laryngeal cancer was considered to be highly effective.

Organ preservation surgery for laryngeal cancer: The evolving role of the surgeon in the multidisciplinary head and neck cancer team

Total laryngectomy is in the doghouse. It is a procedure that was once heralded as a life saving intervention, standing the test of time for over a century. Now largely considered a salvage procedure, total laryngectomy is seen as a second choice following the failure of other approaches. Today, the first line treatment for many patients with advanced laryngeal cancer is the organ-preserving treatment of chemotherapy and radiation therapy. The VA trial showed us that chemotherapy and radiation therapy results in equal survival for patients undergoing total laryngectomy, compared with those who underwent induction chemotherapy and radiation therapy.’ The RTOG 97-l 1 trial demonstrated that concomitant chemotherapy and radiation are superior to either induction chemotherapy or radiation alone in the context of organ preservation for advanced laryngeal cancer. * Both valuable studies have significantly improved the management of laryngeal cancer. It has been suggested that concomitant chemotherapy and radiation therapy should now be the standard of care for laryngeal cancer, replacing total laryngectomy. Patients want to save their larynx, so of course chemotherapy and radiation treatment is good thing. Can there be too much of a good thing?

Radiotherapy versus open surgery versus endolaryngeal surgery (with or without laser) for early laryngeal squamous cell cancer.

Radiotherapy, open surgery and endolaryngeal excision (with or without laser) are all accepted modalities of treatment for early stage glottic cancer. Case series suggest that they confer similar survival advantage. Opinions on optimal therapy vary across disciplines and between countries. To compare the effectiveness of open surgery, endolaryngeal excision (with or without laser) and radiotherapy in the management of early glottic laryngeal cancer Electronic search of MEDLINE (from 1966 to October 2000), EMBASE (from 1980 to October 2000), CINAHL (from 1982 to October 2000) and CancerLit (from 1963 to October 2000) databases and the Cochrane Controlled Trials Register. Randomised controlled trials (RCT) comparing open surgery, endolaryngeal resection and/or radiotherapy Two reviewers independently assessed RCTs identified from the electronic searches for eligibility and methodological quality. All authors of the review discussed the results of these assessments. Only one RCT was identified which compared open surgery and radiotherapy among a substantial number of patients with early glottic laryngeal cancer. There is currently insufficient evidence to guide management decisions on the most effective treatment. Interpretation of the only large scale RCT comparing open surgery and radiotherapy in patients with early glottic cancer is limited because of concerns about the adequacy of treatment regimens and deficiencies in the reporting of the study design and analysis. Endolaryngeal resection of early glottic tumours is becoming more common and a well designed multicentre RCT is warranted.

Near-total laryngectomy for laryngeal carcinomas with subglottic extension.

To investigate whether Pearson classic near-total laryngectomy is a sensible surgical treatment modality for laryngeal carcinomas with subglottic extension. Retrospective analysis of patients treated by near-total laryngectomy in a university hospital that is an academic tertiary health care center. Medical and computer records of 135 patients who were treated by near-total laryngectomy for laryngeal and hypopharyngeal carcinomas between April 1, 1989, and June 30, 2000, were searched thoroughly, and the final outcomes were confirmed by telephone contact. Survival rates of the patients with laryngeal carcinomas with subglottic extension treated by near-total laryngectomy were compared with those of the patients with malignancies of other laryngeal regions given the same treatment. Of the 135 patients in the study, 74 were available for determination of 5-year survival. The rate was 65.8% (27/41) for transglottic tumors, 53.8% (7/13) for supraglottic tumors, and 20.0% (4/20) for tumors with subglottic extension. Only 3 of 16 patients with laryngeal carcinomas with supraglottic or transglottic localization died of local recurrence; the rest of the deaths were from regional recurrence or distant metastasis. However, 6 of 13 patients with subglottic extension died of local recurrence, 5 of peristomal recurrence, and only 2 of distant metastasis. Success was directly related to adherence to precise indications in cancer surgery. While near-total laryngectomy is an effective and reliable treatment modality in laryngeal cancer surgery, its effectiveness in laryngeal cancers with subglottic extension is debatable. These subglottic lesions should be treated by total laryngectomy, which is a more radical surgery.

Stenting of Atherosclerotic Stenoses of the Extracranial Carotid Artery

Percutaneous transluminal angioplasty (PTA) and stenting seems to be, at present, the treatment of choice for early restenosis after endarterectomy and for atherosclerotic stenoses of supra-aortic trunks near or at the ostium. In contrast, the role of PTA and stenting for treatment of symptomatic and asymptomatic atherosclerotic stenosis of carotid bifurcation is still debated. The present study comprises 27 consecutive cases of atherosclerotic lesions of the carotid bifurcation treated with PTA and stenting. All patients were symptomatic, except for 2 suffering from asymptomatic stenosis with contralateral carotid occlusion. There were 23 stenoses occluding 70% or more of the lumen according to the NASCET criteria and 4 mild stenoses (50-60% of the lumen) with large type C ulcers. Criteria for exclusion from surgery in these cases were aged >79 years, previous neck surgery for laryngeal cancer, carotid bifurcation at C2, association with intracranial aneurysms, occlusion of the contralateral carotid artery, and heart, lung and kidney diseases. All procedures were performed under local anaesthesia associated with mild sedation in a few cases. In all cases, self-expandable stents (Wallstent) were used. Follow-up ranged from 6 to 37 months. Transient neurological deficit occurred in 3 cases (11%). One case (3.7%) experienced a minor stroke at three months. Asymptomatic tight restenosis due to intimal hyperplasia occurred in one case (3.7%). In 8 cases (40%) of complex stenosis involving common and internal carotid arteries there was some loss of contact of the stent with the wall of the common carotid artery in the late follow-up. One case (3.7%) experienced severe and prolonged hypotension and bradycardia during the release of the stent. From literature data and our results it emerges that periprocedural catastrophic embolism is unlikely to occur. The best results are undoubtedly obtained when treating stenosis limited to the internal carotid artery. Nevertheless, the ideal stent to treat vessels of different calibre, as occurs at the carotid bifurcation, is not yet available. The problem of periprocedural cerebral protection has not been resolved. Reported series are heterogeneous and retrospective, and an adequate follow-up of cases is still lacking.

Quality of life after treatment for early laryngeal carcinoma.

Radiotherapy and surgery for early laryngeal cancer achieve comparably good results in patient survival, and the choice of treatment between them is being influenced increasingly by the expected voice quality and quality of life (QoL). The superiority of vocal function after radiotherapy has been shown in previous objective voice assessment studies. This study compared the QoL of long-term survivors after endoscopic laser surgery or radiotherapy for early laryngeal carcinoma. QoL was evaluated with two validated questionnaires: the global EORTC QLQ-C30 and the head- and neck-specific EORTC QLQ-H&N35. A total of 62 patients were included. Among 56 patients completing the questionnaires (90% completion rate) 40 were treated by endoscopic CO2 laser surgery and 16 with radiation therapy. All 56 patients showed a good global QoL with no significant difference between the two treatment modalities. The head- and neck-specific evaluation revealed significantly better scores for surgically treated patients in questions about swallowing of solid food, xerostomia, and tooth problems, but no difference in questions about voice quality. Both treatment modalities achieve good QoL after treatment of early laryngeal tumors. Irradiated patients mainly complain about xerostomia related problems. In contrast to objective measurements long-term survivors after surgery do not rate their voice poorer than irradiated patients. The EORTC questionnaires are validated and useful tools in assessing QoL and should further be used in prospective trials.

Intraoperative management of the thyroid gland in laryngeal cancer surgery.

To determine if it is necessary to perform a hemithyroidectomy routinely with all total laryngectomies or if it should be reserved for selected cases. A retrospective analysis of 215 cases who had been operated on due to laryngeal cancer in our clinic between 1985 and 1999. In only 182 cases, hemithyroidectomy and isthmectomy were performed together with laryngeal surgery. Of these, 98% were male. Their ages ranged between 42 and 70 years. The tumour was located in the supraglottic region in 93 (51%) and in the glottic region in 24 (13%) cases. In 65 cases (36%), the tumour was transglottic. Twenty cases of transglottic tumours (31%) and 3 cases of glottic tumours (12.5%) were found to have subglottic extension. Total laryngectomy with unilateral or bilateral neck dissection and hemithyroidectomy on the tumour side plus isthmectomy were performed on all patients. On the pathologic specimens, subglottic extension was measured anteriorly and posteriorly from the free edges of the vocal cords. The specimens were stained with hematoxylin and eosin and examined under a light microscope. With glottic and transglottic carcinomas, the need for thyroidectomy may be based on the intraoperative assessment of the thyroid gland. In subglottic carcinomas, a hemithyroidectomy should routinely be performed. There may be no need to perform thyroidectomy in all total laryngectomy cases. The thyroid gland was invaded by squamous cell carcinoma in only 2 cases (1%). Both of these cases were transglottic tumours staged as T3 and T4 and had a subglottic extension more than 1 cm. We recommend routine hemithyroidectomy and isthmectomy during total laryngectomy only in cases with subglottic extensions more than 1 cm or thyroid cartilage invasion with tumour. In the other cases, assessment of extralaryngeal invasion and thyroid gland invasion by the tumour will determine whether thyroidectomy should be performed.

Cervical osteophytes impinging on the pharynx: importance of size and concurrent disorders for development of aspiration.

This study evaluated the clinical significance of cervical osteophytes impinging on the pharynx in patients with dysphagia and the importance of concurrent disorders that may affect swallowing function. On videofluoroscopy, anterior cervical osteophytes were found in 55 (32 men, 23 women; mean age, 69 years) of 3318 patients with dysphagia (1.7%). Coexisting diseases that affected swallowing function were found in 28 patients (stroke, n = 7; thyroidectomy, n = 7; tongue base or laryngeal cancer surgery, n = 5; other diseases, n = 9). Swallowing function was assessed with videofluoroscopy evaluating epiglottic tilting, laryngeal closure, impression of the hypopharynx, pharyngeal residue, and aspiration. With advancing age, the probability of aspiration (odds ratio, 1.07; p < 0.05) and of enlarging osteophytes (odds ratio, 1.26; p < 0.01) increased; the probability was higher for osteophytes at more than one vertebrae (odds ratio, 8.00; p < 0.01) and for concurrent diseases (odds ratio, 8.02; p < 0.01). Aspiration was found in 75% of patients with osteophytes larger than 10 mm and in 34% with osteophytes smaller than or equal to 10 mm. In 88% of patients with small osteophytes who aspirated, other diseases affected swallowing function. Aspiration is common in patients with dysphagia and cervical osteophytes larger than 10 mm. Aspiration is rare in patients with osteophytes smaller than or equal to 10 mm unless these patients suffer from other disorders that may affect swallowing.

Additive Conjoint Measurement for Multiattribute Utility

This paper shows that the role of risky alternatives can be greatly reduced in the clicitation procedures of multiattribute utility. This reduction can be achieved by invoking methods from additive conjoint measurement; it is desirable because risky choices involve more cognitive problems, thus more biases and unreliability, than riskless ones. Existing results of multiattribute utility are generalized to obtain a complete axiomatization of the new clicitation procedure. The approach has been developed in a medical decision analysis project to advise on the choice between surgery and radiotherapy for laryngeal cancer.

Laryngeal cancer in Colorado.

Previous studies of laryngeal cancer have shown a decrease in the male-to-female ratio and that the sex ratio in glottic tumors is higher than that for other laryngeal sites. The purpose of this study was to characterize and identify changes in the demographics, laryngeal site predilection, geographic distribution, trends in tumor stage at diagnosis, and surgical caseload distribution in Colorado. The Colorado Central Cancer Registry for the years 1979 to 1990 was reviewed for cases of laryngeal cancer. The data were analyzed using chi-square and gradient-in-proportions methods. One-thousand two-hundred sixty-five (1265) cases were identified with a male-to-female ratio of 4.3:1. There was a significant trend of an increasing proportion of cases attributable to women. Glottic carcinoma accounted for 50.1% of cases, with a male-to-female ratio of 7.6:1. The Denver metropolitan area accounted for 57% of all cases, which was not disproportionate to the population. From 1981 to 1990 there was a significant decrease in the proportion of stage I cases and an increase in stage II cases. The teaching hospitals associated with the University of Colorado were responsible for performing 44.5% of all surgery for laryngeal cancer. The results indicate that laryngeal cancer in Colorado shares similar epidemiologic characteristics to those reported in other studies. Of most concern is the increasing proportion of women with laryngeal cancer and the decrease in cases diagnosed at stage I.

The intraoperative management of the thyroid gland during laryngectomy

The standard of care of laryngeal cancer surgery is wide field excision of the larynx combined with ipsilateral thyroid lobectomy. A retrospective review of 247 laryngectomies performed between 1979 and 1989 was undertaken to determine specific intraoperative indications for thyroid gland removal. The incidence of thyroid disease in our patients with laryngeal cancer was compared to the normal population. Eight percent of thyroid specimens removed during laryngeal cancer surgery demonstrated invasion by squamous cell carcinoma. All patients having thyroid invasion had T3 or T4 laryngeal lesions that were stage IV at the time of surgery. All these lesions were found to have transglottic growth and laryngeal cartilage invasion by the pathologist. All of these patients also had abnormal thyroid glands intraoperatively and laryngeal cartilage destruction that was evident intraoperatively. Total thyroidectomy with bilateral paratracheal and pretracheal lymph node dissection is indicated when squamous cell carcinoma of the larynx involves the thyroid gland. Prophylactic ipsilateral thyroid lobectomy and isthmusectomy is warranted for large laryngeal cancers (T3, T4) that involve the anterior commissure, the subglottic area, or extend transglottically. Routine thyroid gland removal is not indicated for the majority of laryngeal cancers that do not meet the aforementioned criteria. Finally, abnormal thyroid histopathology was diagnosed in 37% of the surgical thyroid gland specimens removed during laryngectomy.

Results of laryngeal cancer surgery in four ENT centers in poland.

The results of laryngeal cancer surgery were assessed in a group of 832 patients treated in four major ENT centers in Poland. Five-year survival rates were as follows: stage I, 86%; stage II, 71%; stage III, 54%; and stage IV, 42%. In experienced hands and for properly selected cases, cure rates after partial (conservation) laryngeal surgery were similar to those after total laryngectomy. For early stages (I and II), the survival after partial surgery was better than that found after radiotherapy.

Surgery of the Larynx

This is an excellent book on laryngology with special emphasis on laryngeal surgery. Dr Byron Bailey and his coeditor, Dr Hugh Biller, have done a superb job of arranging and editing this multiauthored text. The bibliography is up-to-date, and the illustrations are generally good. The strength of this book is in its updating the serious student of laryngology on the various surgical techniques in benign and malignant disorders. I was especially pleased to see excellent chapters on developmental anatomy by John Tucker and physiology of the larynx by Clarence Sasaki. Cancer surgery and rehabilitation are well covered in ten excellent chapters, which more than adequately deal with indications, techniques, and complications of laryngeal cancer surgery. The controversial issues in reinnervation of the larynx are discussed ably by Harvey Tucker and Roger Crumely. As is common in a book of this type, certain omissions and weaknesses occur. A chapter on laser

Conservation surgery for laryngeal cancer.

Conservation surgery for laryngeal cancer.