Laryngeal Preservation Surgery Research Articles

Neoadjuvant chemotherapy combined with PD-1 inhibitor for laryngeal preservation in locally advanced hypopharyngeal squamous cell carcinoma: A single-arm, phase II clinical trial.

e18035 Background: Neoadjuvant chemotherapy (NCT) combination with PD-1 inhibitor has a significant efficacy and approved indications in the first-line treatment of R/M head and neck squamous cell carcinoma (HNSCC), but the efficacy of the combination therapy in locally advanced hypopharyngeal squamous cell carcinoma (HPSCC) remains unexplored. This study aimed to explore the efficacy and safety of NCT with PD-1 inhibitor for laryngeal preservation in patients with HPSCC. Methods: Patients with cT1N1-3M0 or cT2-3N0-3M0 (AJCC 8th) were eligible after multidisciplinary team (MDT) discussion. All patients received 2 cycles of intravenous docetaxel (60mg/m2 on d1), cisplatin (60mg/m2 on d1), fluorouracil (600mg/m2 per day as a continuous 120h infusion on d1-5) and toripalimab (240mg on d1) every 21 days. And the MDT underwent efficacy evaluation according to RECIST 1.1. Patients with complete response (CR)/partial response (PR) of the primary lesion(P) and no progressive disease (PD) in neck lymph nodes (LN) received definitive radiotherapy (RT) combined with toripalimab. Patients with stable disease (SD)/PD of P and no PD in LN or with PD in LN underwent surgery. Patients completed the third cycle of neoadjuvant therapy(NAT) before RT or surgery. The primary endpoint was the CR rate at 3 months (3m-CR) after NAT and definitive RT, and the secondary endpoints were the objective response rate (ORR) of NAT, laryngeal preservation rate, and adverse effects(AE). The sample size was calculated by the Simon-II-stage method: 27 patients in first stage (if ≥9 patients got 3m-CR, second stage started) , and a cumulative total of 81 patients in second stage. Results: From October 2020 to August 2023, 23 patients (median age:59, range:51-69, male:100%, stage II/III/IVA/IVB:4.3%/4.3%/26.1%/65.2%) were enrolled. After NAT, the ORR of primary tumor was 78.3% (18/23, including 2 CR), the ORR of lymph node was 65.2%% (15/23, including 9 CR), and the overall ORR was 70.0% (16/23). Fifteen patients received non-surgical treatment after NAT, and 8 patients underwent surgery (6 underwent laryngeal preservation surgery). At 3 months after RT or surgery, 18 patients completed evaluation. The CR rate was 77.8%, and the laryngeal preservation rate was 88.9%. In 13 evaluable patients who received NAT followed by definitive RT, 10 patients (76.9%) had an overall response of 3m-CR. During the NAT, 43.5% (10/23) of patients experienced grade 3-4 AEs, with grade 3-4 leukopenia or neutropenia in 30.4% (7/23) and grade 3 immune enteritis in 13.0% (3/23). Conclusions: NCT combination with PD-1 inhibitor may improve the ORR of HPSCC, potentially further increasing the laryngeal preservation rate, with manageable treatment-related AEs. The study results are pending publication after completion of the enrollment. Clinical trial information: NCT04624308 .

Neoadjuvant therapy with chemotherapy and immune checkpoint inhibitor for laryngeal function preservation in locally advanced hypopharyngeal cancer.

To evaluate the efficacy and laryngeal function preservation of neoadjuvant treatment with chemotherapy and immune checkpoint inhibitor for locally advanced hypopharyngeal cancer (LAHPC). We retrospectively collected LAHPC patients who were diagnosed between February 2022 and June 2023. The patients received a combination of chemotherapy and immune checkpoint inhibitors as the neoadjuvant therapy. The response to treatment, laryngeal function preservation rate, and short-term survival were assessed. A total of 20 patients were included. Of these patients, 17 (85.0%) had stage IVA-B disease. Ten (50%) and four (20%) patients achieved pathological complete response (PCR) and major pathological response (MPR) to the primary tumor, respectively. In addition, 6 patients had incomplete pathological response (IPR). In the neck, 19 patients had node-positive disease before treatment, and only 5 patients (26.4%) had PCR to regional lymph nodes. Pathologically positive lymph nodes were still observed in 14 (73.6%) patients. Significant downgrading on narrow-band imaging assessment in primary tumors was associated with a higher probability of PCR or MPR than those with IPR (92.9% vs. 33.3%, P=0.014). The overall rate of laryngeal preservation was 95.0%. No severe perioperative complications or perioperative death were found. All patients completed the recommended postoperative radiotherapy/chemoradiotherapy. The median follow-up period was 12.1 months. The 1-year progression-free survival and overall survival were 94.1% and 92.9%, respectively. During the follow-up period, all 19 patients who underwent laryngeal preservation surgery had their laryngeal function preserved. The addition of an immune checkpoint inhibitor to neoadjuvant chemotherapy effectively preserves laryngeal function without increasing complications related to surgery and postoperative radiotherapy in LAHPC.

A Case of Thyroid Chondrosarcoma

We herein report a rare case of thyroid chondrosarcoma in which laryngeal preservation surgery was performed. The patient was a man in his 40s. A hard mass was palpated on the right lateral side of the thyroid cartilage. Enhanced computed tomography showed a tumor on the right lateral side of the thyroid cartilage with partial destruction of the thyroid cartilage. Ultrasonography-guided fine-needle aspiration cytology suggested the lesion was a tumor of cartilage origin. We therefore diagnosed a thyroid cartilage tumor. We performed partial laryngectomy. Intraoperative findings revealed a hard tumor contiguous with the thyroid cartilage deep in the right omohyoid muscle. The right two-thirds of the thyroid cartilage were cut longitudinally, and the tumor was removed. The pathological diagnosis was a grade 2 chondrosarcoma of thyroid cartilage origin. Two years after surgery, there was no recurrence. There have been 37 cases of laryngeal chondrosarcoma reported in Japan, and only 8 were of thyroid cartilage origin. Surgical treatment was selected in all cases, with 16 cases treated by total laryngectomy and 21 cases by partial laryngectomy. Recurrence was reported in five cases, including local recurrence in three cases, cervical recurrence in one case, and distant metastasis in one case.

Application of transverse cervical artery flap in laryngeal function preservation surgery of hypopharyngeal carcinoma

To explore the value and limitation of transverse cervical artery flap in laryngeal function preservation surgery of hypopharyngeal carcinoma. Between January 2013 and December 2019, 18 male patients with hypopharyngeal carcinoma were admitted. The patients' age ranged from 48 to 77 years, with a median age of 65 years. The disease duration ranged from 3 to 8 months (mean, 5 months). All patients were diagnosed as squamous cell carcinoma by biopsy before operation. According to the American Joint Committee on Cancer (AJCC) guidelines (2017, 8th ed), TNM staging was T2N0M0 in 9 cases, T2N1M0 in 2 cases, and T3N0M0 in 7 cases, and cTNM staging was stage Ⅱ in 9 cases and stage Ⅲ in 9 cases. The lesions of 15 cases were located in the piriform fossa of hypopharynx on one side, among which the esophageal entrance was involved in 4 cases. The lesions of 3 cases were located in the posterior wall of the hypopharynx with esophageal entrance involvement. After partial pharyngo- laryngectomy and bilateral neck lymph node dissection, the hypopharyngeal and laryngeal defects were repaired with transverse cervical artery flaps, the size of the flap ranged from 4 cm×3 cm to 6 cm×4 cm. The accompanying vein of transverse cervical artery (7 cases), external jugular vein (6 cases), and combination of both (5 cases) served as venous reflux. Retrograde external jugular venous reflux exercise was performed in 2 flaps with venous reflux obstruction during operation. The incisions at donor sites were directly sutured or via relaxed incision sutured. Radiotherapy and chemotherapy were supplemented within 3 months after operation. Tracheal cannula with air bag was used to prevent patients from aspiration in the early postoperative stage. The operation time was 4-6 hours, with an average of 4.5 hours. All patients were followed up 1-5 years (mean, 2 years and 6 months). Postoperative pathological examination showed that 7 cases had cervical lymph node metastases on the affected side, and there was no lymph node metastasis in cervical region Ⅴ; the remaining 11 cases had no lymph node metastasis. After operation, 16 flaps survived successfully, and 2 flaps with external jugular vein reflux were covered with white pseudomembrane, no flap necrosis was found after the pseudomembrane fell off. Four cases had no obvious accidental aspiration after operation; 14 cases had obvious accidental aspiration, of which 13 cases were significantly reduced at 3 months after operation, and 1 case still had obvious accidental aspiration at 6 months after operation, and the accidental aspiration decreased significantly after pulling out the gastric tube. All patients had no aspiration pneumonia. One case developed upper mediastinal lymph node metastasis at 1 year and 2 months after operation, and died of recurrence and pulmonary infection at 1 year and 3 months after operation. No recurrence or metastasis was found in the remaining 17 cases during follow-up. Tracheal cannula was successfully removed in 7 cases at 2-5 months after operation. Different degrees of accidental aspiration in 11 patients were confirmed by esophagography, so the tracheal cannula was retained. All patients had pronunciation function after operation. All incisions at the donor sites healed by first intention, and the shoulder joint function was normal. Using transverse cervical artery flap to repair the hypopharyngeal and laryngeal defects during hypopharyngeal carcinoma surgery in patients without lymph node metastasis in cervical region Ⅴ, can achieve good results of laryngeal function preservation. In cases with suspected lymph node metastasis in cervical region Ⅴ or venous dysplasia of accompanying vein of transverse cervical artery, there is a risk of tumor recurrence or flap necrosis, and the repair method needs to be cautiously employed.

Organ Preservation Strategies in Laryngeal Chondrosarcoma.

Laryngeal chondrosarcoma (LC) is a rare, slowly growing malignancy. The preferred treatment is laryngeal preservation surgery (LPS). Some patients may require multiple interventions or total laryngectomy (TL). We investigated risk factors for retreatment and TL, and assessed the impact of LPS on oncological and functional outcomes. Case series METHODS: We searched our institution database for LC. Tumor grading, localization, and margin status were tested as predictors of recurrence and organ preservation. We included 21 patients (seven females, mean age 58 ± 12 years). LPS was applied in 20 (95.2%) of them as a primary procedure. Six patients were treated by transoral approach and 14 received "open-neck" LPS. Fifteen (71.4%) were operated only once, while six patients underwent a total of 15 adjunctive procedures. Additional operations were always performed for recurrence of tumors localized within the cricoid plate. The histological grading was G1 in 81% and G2 in 19%. However, two patients with a primary G1 LC showed a G2 recurrence. Reoperations for recurrence were more frequent among patients with G2 in respect to G1 histology (83% vs. 7%, P < .001). Fifty percent of G2 LC and 8% of G1 underwent TL (P < .05). Margin status had no influence on recurrence rate. Patients with G2 LC have more recurrences requiring surgery and a higher incidence of TL. Cricoid plate localization is relevant for organ preservation. Margin status signals possible disease persistence, without influencing the need for future surgeries. Need for reoperation entails a risk of not being able to maintain organ functionality. 4 Laryngoscope, 132:838-843, 2022.

Laryngeal Preservation Surgery for Hypopharyngeal and Cervical Esophageal Cancer —Indications and Problems—

Laryngeal Preservation Surgery for Hypopharyngeal and Cervical Esophageal Cancer —Indications and Problems—

Changing trend in prognosis of primary hypopharyngeal carcinoma and reason analysis: date comparison of 2003-2007 and 2010-2014 in a single centre

Objective: To explore changing trend in prognosis of primary hypopharyngeal carcinoma and to analyze the reasons at the Eye, Ear, Nose and Throat Hospital of Fudan University. Methods: We retrospectively analyzed the clinical data of 461 patients with primary hypopharyngeal carcinoma treated at the Eye, Ear, Nose and Throat Hospital of Fudan University from 2003 to 2007 (Group 1) and 2010 to 2014 (Group 2) according to the inclusion criteria. 142 from Group 1, including 133 males and 9 females, rangedfrom 38 to 82 years old and 319 from Group 2, including 313 males and 6 females, ranged from 39 to 81 years old, were included in this work. The laryngeal function preservation rate, survival outcome, application and effect of pre-and post-operative adjuvant therapy were compared. SPSS 24.0 was used for statistical analyses. Results: There were 62 patients with early disease (T1-2N0) including 18 in Group 1 and 44 in Group 2, in whom 3 (16.7%) underwent surgical procedures with laryngeal function preservation in Group 1, while, 30 (68.2%) underwent laryngeal function preservation surgery in Group 2. The laryngeal function preservation rate showed an obviously upward trend in recent years (χ(2)=13.617, P<0.001), whereas, the recurrence-free survival rate (RFS) and overall survival rate (OS) showed no significant differences between two groups (P=0.469 and 0.808, respectively). Among the 399 patients with advanced disease, 124 were in Group 1 and 275 in Group 2. After propensity score matching (PSM) was used, the OS rate was significantly higher for Group 2 than Group 1 (P=0.017), while the application of laryngeal function preservation surgery was significantly higher in Group 2 (χ(2)=4.686, P=0.030). The application rates of preoperative adjuvant therapy and postoperative adjuvant chemotherapy were significantly higher in group 2 than in group 1 (χ(2)=5.687, P=0.017; χ(2)=19.407, P<0.001). Conclusion: The application of laryngeal function preserving surgery significantly increases the retention rate of laryngeal functions in patients with early-stage hypopharyngeal carcinoma, with similar long-term survival outcomes. The application of comprehensive treatment including preoperative adjuvant therapy and postoperative adjuvant treatments, especially postoperative chemoradiotherapy, shows an obvious increase in the function preservation rate and long-term survival in patients with advanced hypopharyngeal carcinoma.

Investigation of 71 cases of laryngeal preservation surgery of hypopharyngeal cancer

Investigation of 71 cases of laryngeal preservation surgery of hypopharyngeal cancer

Severe late dysphagia after multimodal treatment of stage III/IV laryngeal and hypopharyngeal cancer.

Long-term side effects after radiotherapy for organ preservation 'could deteriorate' the laryngeal function. This study intended to identify the incidence of severe late dysphagia following the multimodal treatment for stage III/IV laryngeal and hypopharyngeal cancer 'to evaluate the function of larynx'. The medical records of patients successfully treated for laryngeal and hypopharyngeal cancer with a multimodal approach, including radiotherapy, were retrospectively analyzed. 'Functional larynx was defined as tolerable oral diet without severe late dysphagia or tracheostoma'. The study included 99 patients with a median follow-up period of 72months. 'Tracheostomy during the follow-up period was required in only one patient due to aspiration pneumonia, and dysphagia is the main determinant for functional larynx'. The probability of maintaining functional larynx was 63% for 10years, when the treatment was started with radiotherapy or concurrent chemoradiotherapy. In upfront surgery (operation first and adjuvant radiotherapy/concurrent chemoradiotherapy) group, 37% of patients required total laryngectomy as primary treatment and 43% of patients could maintain laryngeal function for 10years. And severe late dysphagia in the latter group developed mainly after laryngeal preservation surgery. The patients aged ≥65years showed significantly higher incidence of dysphagia. Severe late dysphagia was very rare in laryngeal cancer successfully cured with radiotherapy/concurrent chemoradiotherapy (1/25, 4%); however, it gradually increased over time in hypopharyngeal cancer patients showing a statistically significant difference from laryngeal cancer patients (P=0.040). Severe late dysphagia occurred in 19.2% of patients treated for laryngeal and hypopharyngeal cancers, regardless of whether treatment started with radiotherapy/concurrent chemoradiotherapy or surgery.

Limitations and Opportunities in Open Laryngeal Organ Preservation Surgery: Current Role of OPHLs.

The current trend for treatment of intermediate-early advanced laryngeal cancer is essentially oriented toward preservation of organ and laryngeal function, and with a good potential for treating the disease. This goal can be achieved by adopting open laryngeal organ preservation surgery (OLOPS), at present mainly represented by open partial horizontal laryngectomies (OPHLs). An approach using rigorous selection criteria based on both the general condition of the patient and the local and regional extent of the disease gives excellent oncological and functional results in untreated patients. Similar outcomes, albeit slightly worse, are also obtainable in radio-recurrent and laser-recurrent patients. Troublesome postoperative management and the inconsistency of functional recovery are the main limitations for extensive application of this therapeutic strategy. The future direction is represented by simplification of the indications identifying iso-prognostic sub-categories within the T-stage, wider consensus on rehabilitation protocols, hybrid approaches to the larynx, and open minimally invasive access.

Squamous Cell Head and Neck Cancer

This book is part of the Current Clinical Oncology series and is preceded by 14 other topics, notably the common tumours of lung, breast and colorectal as well as more diverse subjects such as hepatocellular carcinoma, myeloma and intra-operative irradiation. Now it is the turn of squamous cell head and neck cancer. This is a multi-author book written by 48 medical/radio oncologists and unashamedly American in perspective with only one author from Europe (Jacques Bernier) and four from the National Cancer Institute of Singapore. In terms of the target audience, this is a studious work with few illustrations, produced in dense type and replete with references. It is a treasure trove for the student writing a paper or applying for a grant but not an easy read. The book does not deal with broad issues and is likely to confuse the uninitiated. The first chapter deals with risk factors for head and neck cancer of those in the population that do not smoke or drink. This small cohort of patients has attracted attention because of the association with human papilloma virus and the potential for a vaccine solution. Other factors addressed are relatively inconsequential such as diet, genetic predisposition, immune deficiency, etc. The next four chapters deal with surgical topics: the first is laryngeal preservation surgery, which is a well-established subject – nothing much new here. The next topic is laser therapy, where the European results of larynx and oropharyngeal surgery are noteworthy. The following chapter discusses the role of neck dissection in the context of organ preservation therapy. The issue is whether a patient with positive cervical lymphadenopathy needs a complete neck dissection after chemoradiation. The answer is that this is only necessary for patients with disease greater than N1. The third chapter deals with surgical salvage after failed chemoradiation (organ preservation therapy) and here there may be a surveillance role for PET in detecting persistent disease. We will have to wait for the answer. Chapters 6–10 deal with radiotherapy issues; first, the management of the T3–T4 tumour of the larynx. The authors provide a wealth of detail on the subject and conclude that careful case selection is important for the outcome. The next chapter deals with brachytherapy, a subject with a long history but again there is little new to report. In chapter 8, intensity-modulated radiation therapy is described but it is too early to expect a realistic account of its performance. However, the next chapter on accelerated and hyperfraction radiation therapy does provide answers within the final analysis – an assertion that the more radiation targeted on the tumour, the greater is the chance of cure. The remaining half of the book covers medical oncology. The role of traditional induction chemotherapy is dispatched quickly but its application in organ preservation is fully developed in the succeeding two chapters. These convey the reality of a fast-moving topic breaking new ground, where the advantage now lies with multimodality therapy. Concomitant chemoradiation gives up to an 8% improvement in survival across all stages of disease. Nevertheless, there is a catch as it does not extend to all age groups, as by the age of 70 years the survival advantage is lost. Chapters 16–19 deal with novel therapies including attempts to protect normal tissue from radiation damage and new therapy targeted at neovascularisation, cell cycle pathways and gene manipulation. Herein lie the innovations for the future and studies are already being designed to trial these molecules in the head and neck. It would be prescient for surgical oncologists to digest the chemoradiation chapters if they want to be prepared for impending environmental change. All in all, this is a book packed with data giving glimpses of the future. It is a must for insomniacs.

Supracricoid Partial Laryngectomy for Primary and Recurrent Laryngeal Cancer

Supracricoid partial laryngectomy (SCPL) is an essential technique in the armamentarium of modern laryngeal organ preservation surgery. OBJECTIVE, DESIGN, SETTING: Retrospective case series to review the oncologic outcomes following SCPL in a large US-based cohort treated by a single surgeon in a tertiary-care university hospital. A total of 96 consecutive patients with primary or recurrent squamous cell carcinoma of the larynx undergoing SCPL from 1992 to 2010. Supracricoid partial laryngectomy surgery. Five-year local control and laryngeal preservation, using the Kaplan-Meier method. There were 54 primary laryngeal carcinomas and 42 previously treated with radiation to the larynx; 23% were supraglottic or transglottic tumors (n = 22). The overall 5-year local control rate for the series was 94%. For T2 and T3 primary tumors, the 5-year local control was 100% and 96%, respectively. In patients previously treated with radiation, the 5-year local control was 89%, with an 89% laryngeal preservation rate. Among stage III or IV primary laryngeal tumors for which concurrent chemoradiation was a treatment alternative, the 5-year local and locoregional control was 96% and 83%, respectively, and the 5-year larynx preservation was 91%. Ultimate local control was achieved for all patients in the series. A significant postoperative complication occurred in 19% (n = 18) and 1 anesthesia-related perioperative death occurred. No total laryngectomies were performed for laryngeal dysfunction. This series demonstrates excellent local control for both primary and recurrent laryngeal cancers, with functional larynx preservation. In appropriately staged and selected patients with T2 or T3 primary laryngeal cancer or laryngeal cancer following prior radiation treatment, SCPL should be considered as a treatment alternative to non-surgical treatment or total laryngectomy.

Alternative treatment option for hypopharyngeal cancer: clinical outcomes after conservative laryngeal surgery with partial pharyngectomy

Conclusion: The oncological and functional outcomes of hypopharyngeal cancer after conservative laryngeal surgery are fairly acceptable, making this a reasonable initial treatment option for selected patients. Objective: The purpose of this study was to assess the clinical outcomes of patients with hypopharyngeal squamous cell carcinoma (SCC) treated with conservative laryngeal surgery with partial pharyngectomy. Methods: Fifty-eight patients with hypopharyngeal SCC who underwent laryngeal preservation surgery were enrolled. The tumors were classified as cT1 in 5 (8.6%) patients, cT2 in 35 (60.3%), cT3 in 14 (24.1%), and cT4a in 4 (6.9%) patients. Results: Surgical outcomes: 5-year overall and disease-specific survival rates were 78% and 77.6%. Recurrent disease developed in 13 patients (22.4%). Multivariate analysis revealed that level VI metastasis confirmed by histopathological analysis, close (< 5 mm) histologic margin, advanced N stage, and posterior pharyngeal wall tumor were independent factors associated with poor disease-specific survival. Functional outcomes: 50 patients (86.2%) could obtain all their nutritional needs orally. Eight patients needed the assistance of a percutaneous endoscopic gastrostomy tube. Oral re-alimentation was achieved within a mean of 26.1 days after surgery. Fifty-one patients (87.9%) could be decannulated after a mean of 43.8 days postoperatively.

進行下咽頭癌T3，4症例の喉頭温存手術の検討

進行下咽頭癌T3，4症例の喉頭温存手術の検討

Treatment outcome comparation of surgery plus radiotherapy and radiotherapy or chemoradiotherapy plus salvage surgery for stage III/IV laryngeal carcinoma

Objective To compare the treatment outcome of underwent surgery plus radiotherapy and radiotherapy/chemoradiotherapy plus salvage surgery for stage Ⅲ/Ⅳ laryngeal carcinoma,to investigate an optimized treatment for the patients of stage Ⅲ/Ⅳ laryngeal carcinoma.Methods Clinical data from 103 patients with stage Ⅲ (39 cases) or stage Ⅳ (64 cases) laryngeal carcinoma were retrospectively analyzed.The patients were divided into surgery plus radiotherapy group (S±R,46 cases) and radiotherapy/chemoradiotherapy plus salvage surgery group (R±S,57 cases).Overall survival,relapse free survival,and laryngeal preservation rate were used to compare the treatment outcome between two groups.Multivariate regression models were used to analyze the independent factors for survival and laryngeal preservation rate.Results Survival rate was higher in S±R group than in R±S group [2 year overall survival/relapse free survival 74.7 ％ (34/46) / 72.4 ％ (33/46) vs 46.4 ％ (26/57) / 40.9 ％ (23/57),P ＜ 0.05].Laryngeal preservation rate was higher in R±S group than in S±R group [93.0 ％ (15/46) vs 32.6 ％ (53/57),P ＜ 0.05].Multivariate analysis demonstrated that treatment modality and T stage were independent factors for long-term survival,while treatment modality was the only an independent factor for laryngeal preservation rate.Conclusions Surgery plus radiotherapy result in better survival and lower laryngeal preservation rate than radiotherapy/chemoradiotherapy plus salvage surgery in treatment of stage Ⅲ/Ⅳ laryngeal carcinoma.Surgery plus radiotherapy should be the first choice for treatment of locally advanced laryngeal carcinoma.Improvement of the quality of life could be achieved by laryngeal preservation surgery and phonation reconstruction procedures. Key words: Laryngeal neoplasms; Radiotherapy, computer assested; Surgery; Survival

Clinical analysis of outcome of laryngeal preservation surgery for hypopharyngeal cancer—Postoperative complications and management—

2004年から2008年までに当科で一次治療を行った喉頭温存手術を施行した下咽頭癌8症例を対象に，術後合併症，術後管理上の問題点について検討した。術後合併症に関して，全例で患側反回神経麻痺を認め，半数の症例で嚥下障害や嚥下性肺炎を認めた。さらに嚥下障害症例中の1例で退院後も経管栄養が必要となり，嚥下性肺炎症例中の1例で膿胸と薬剤性腎障害を併発した。術式の検討からは，下咽頭全周切除，遊離空腸管状再建症例で嚥下障害，嚥下性肺炎の発症頻度が高かった。術後管理上の問題点として，気管孔閉鎖不全によるエアリークや，鎮静剤，抗うつ剤などの使用による胃腸蠕動運動の抑制が，嚥下性肺炎発症のきっかけになっていると考えられた。

Clinicopathological Analyses of Fifty Supracricoid Laryngectomized Specimens: Evidence Base Supporting Minimal Margins

Objectives: Supracricoid laryngectomy (SCL) is a reliable laryngeal preservation surgery. However, close surgical margins are often inevitable. Based on clinicopathological analyses of supracricoid laryngectomized specimens, we evaluated the evidence base supporting minimal margins. Methods: The distance between tumor edge and resected margin was measured macro- and microscopically at the anterior, posterior, superior and inferior edges, using 50 surgical specimens. The margins were correlated with pathological T staging and the prognoses. Results: The anterior and posterior margins were the shortest, and the superior margin was the longest. The inferior margin was the only edge at which a positive margin was encountered. Cancer extending 10 mm below the glottal free edge significantly decreased the inferior margin. Conclusions: The surgical potential of SCL with cricohyoidoepiglottopexy was confirmed to be able to cope with tumor extensions showing margins of a few millimeters at the anterior, posterior and superior ends. Accurate assessment and management at the inferior margin is the key to stable local control.

Relationship between extent of resection and reconstruction in laryngeal preservation surgery for hypopharyngeal cancer

喉頭温存・下咽頭喉頭部分切除術で，適切な再建術選択の指針は確立されていない。そこで2004年4月より当科で本術式を行った23例を対象として，切除範囲と再建法について検討を行った。一側の披裂喉頭蓋襞と梨状陥凹に留まる切除なら一期縫縮が可能であった。一側の梨状陥凹を越えて後壁や輪状後部に達する切除や，一側の披裂喉頭蓋襞を越えて披裂上半分を含む切除では空腸パッチ再建が必要であった。T3・T4進行癌でも，喉頭温存手術の可能な症例が認められた。一期縫縮例では平均2週間，再建症例では平均3週間で術後経口再開が可能であった。完全喉頭機能温存が約8割の症例で成され，疾患特異的生存率が約9割であった。

Surgery in the Management of Laryngeal and Hypopharyngeal Carcinoma

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.

Squamous Cell Head and Neck Cancer

This book is part of the Current Clinical Oncology series and is preceded by 14 other topics, notably the common tumours of lung, breast and colorectal as well as more diverse subjects such as hepatocellular carcinoma, myeloma and intra-operative irradiation. Now it is the turn of squamous cell head and neck cancer. This is a multi-author book written by 48 medical/radio oncologists and unashamedly American in perspective with only one author from Europe (Jacques Bernier) and four from the National Cancer Institute of Singapore. In terms of the target audience, this is a studious work with few illustrations, produced in dense type and replete with references. It is a treasure trove for the student writing a paper or applying for a grant but not an easy read. The book does not deal with broad issues and is likely to confuse the uninitiated. The first chapter deals with risk factors for head and neck cancer of those in the population that do not smoke or drink. This small cohort of patients has attracted attention because of the association with human papilloma virus and the potential for a vaccine solution. Other factors addressed are relatively inconsequential such as diet, genetic predisposition, immune deficiency, etc. The next four chapters deal with surgical topics: the first is laryngeal preservation surgery, which is a well-established subject – nothing much new here. The next topic is laser therapy, where the European results of larynx and oropharyngeal surgery are noteworthy. The following chapter discusses the role of neck dissection in the context of organ preservation therapy. The issue is whether a patient with positive cervical lymphadenopathy needs a complete neck dissection after chemoradiation. The answer is that this is only necessary for patients with disease greater than N1. The third chapter deals with surgical salvage after failed chemoradiation (organ preservation therapy) and here there may be a surveillance role for PET in detecting persistent disease. We will have to wait for the answer. Chapters 6–10 deal with radiotherapy issues; first, the management of the T3–T4 tumour of the larynx. The authors provide a wealth of detail on the subject and conclude that careful case selection is important for the outcome. The next chapter deals with brachytherapy, a subject with a long history but again there is little new to report. In chapter 8, intensity-modulated radiation therapy is described but it is too early to expect a realistic account of its performance. However, the next chapter on accelerated and hyperfraction radiation therapy does provide answers within the final analysis – an assertion that the more radiation targeted on the tumour, the greater is the chance of cure. The remaining half of the book covers medical oncology. The role of traditional induction chemotherapy is dispatched quickly but its application in organ preservation is fully developed in the succeeding two chapters. These convey the reality of a fast-moving topic breaking new ground, where the advantage now lies with multimodality therapy. Concomitant chemoradiation gives up to an 8% improvement in survival across all stages of disease. Nevertheless, there is a catch as it does not extend to all age groups, as by the age of 70 years the survival advantage is lost. Chapters 16–19 deal with novel therapies including attempts to protect normal tissue from radiation damage and new therapy targeted at neovascularisation, cell cycle pathways and gene manipulation. Herein lie the innovations for the future and studies are already being designed to trial these molecules in the head and neck. It would be prescient for surgical oncologists to digest the chemoradiation chapters if they want to be prepared for impending environmental change. All in all, this is a book packed with data giving glimpses of the future. It is a must for insomniacs.