Stomal Recurrence Research Articles

Elective neck dissection in supraglottic carcinoma

Between 1979 and 1991, 209 of 316 patients with previously untreated supraglottic squamous cell carcinomas were diagnosed as clinical N0. Of those, 148 cases treated by surgery were investigated retrospectively as to occult neck metastases in order to decide the indication of an elective neck dissection on the basis of clinical features of primary lesions by means of T classification and Sato's classification. According to this classification, supraglottic carcinomas are classified into the following three groups : epilarynx, supraglottis and transglottis. Furthermore, each is divided into median type and lateral type respectively. More than 20% incidence of occult neck metastases may be regarded as high risk and justify elective neck dissection. Occult neck metastases were shown in 46 of 148 cases (31 %), especially 20 bilaterally and 4 as stomal recurrences. The incidence of occult neck metastases according to T classification was as follows : T1, 0 % (0/1) ; T2, 17% (9/54) ; T3, 36% (24/66) ; T4, 48% (13/27). The incidence of ones in T2 according to Sato's classification was as follows : transglottis, anterior type, 8% (1/13) ; transglottis, lateral type, 29% (2/7) ; supraglottis, median type, 25% (3/12) ; supraglottis, lateral type, 14% (3/22). Addition of Sato's classification suggested the possibility of selection of high risk cases in T2. No contralateral neck metastases was found in transglottic lateral type. Our study clearly demonstrates that the indication of an elective neck dissection in supraglottic carcinoma should be T3, T4 and part of T2 cases (transglottis, lateral type and supraglottis, median type) and bilateral jugular node dissection (lateral neck dissection) should be required of all but ones in transglottis, lateral type.

Subglottic cancer

In summary, subglottic tumors are fortunately uncommon. They tend to present late with extensive disease, and are difficult to assess clinically. CT and MRI can be helpful in this regard. They have a tendency for extra laryngeal spread and paratracheal lymph node metastases. Aggressive surgical therapy is therefore recommended. This usually includes a wide field laryngectomy, an adequate low tracheal margin, and bilateral paratracheal lymph node dissection. The thyroid gland should be removed on the ipsilateral side, and if there is evidence of gross invasion of the thyroid gland, total thyroidectomy should be performed. Postoperative radiation therapy is recommended to both sides of the neck, stoma, and upper mediastinum. This will hopefully reduce the risk of stomal recurrence.

Neoplasms of the larynx, edited by alfio ferlito, md, 618 pages, churchill livingstone inc., new york, 1993, $195.00

Historical perspective embryology and anatomy epidemiology laryngeal cancer - a preventable disease experimental carcinogenesis special techniques in diagnostic pathology historical classification recurrent respiratory papillomatosis precursors of squamous cell carcinoma neuroendocrine neoplasms malignant melanoma salivary gland neoplasms soft tissue neoplasms cartilagineous and osteogenic neoplasms neoplasms of lymphoid and haematopoietic tissues blastoma, hamartoma and teratoma secondary neoplasms clinical manifestations and diagnostic procedures documentation diagnostic imaging TNM classification according to UICC and AJCC perioperative medical considerations surgical therapy rationale for evaluation and treatment of the neck treatment with CO2 laser radiation therapy chemotherapy voice rehabilitation after total laryngectomy stomal recurrence after total laryngectomy management of complications of surgical intervention retreatment prognostic factors routines for follow-up and risk for multiple primaries psychological aspects.

Basaloid-squamous Cell Carcinoma of the Larynx and Hypopharynx: A Clinicopathologic Study of 7 Cases

During a 16-year period (1974-1989), a retrospective review of 468 surgical specimens of laryngectomy yielded 7 cases (0.66%) of basaloid-squamous cell carcinoma. They were all males between 42 and 63 years of age. Four cases were supraglottic and one transglottic. The other two arose in the left pyriform sinus and vallecula, respectively. At diagnostic time, 4 cases were Stage III and 2 Stage IV, only one being Stage II. Glanz index of histologic malignancy was high (> 5) in most cases (6/7). Mitotic rate was also high (22-78 mitoses/10 HPF). Lymph node metastases were documented at diagnosis in 5 cases, 3 of them presenting with extracapsular extension. One case developed liver metastases. During the follow-up, lymph nodes of the neck were again metastasized in 4 cases, and stomal recurrence was present in another one. Death of disease was confirmed in 5 cases after 10 to 35 months of follow-up. Overall survival was 28.5% after 3 years.

Risk factors involved in stomal recurrence following laryngectomy

Stomal recurrence after surgery for laryngeal tumours is an extremely serious complication, with a dismal prognosis despite aggressive surgical therapy or high-dose irradiation. Data from 209 patients who underwent total laryngectomy for cancers of the larynx and hypopharynx were retrieved from the registry of the Department of Otorhinolaryngology at the Hospital 'Virgen de las Nieves' of Granada. Stomal recurrence developed in 8.1 per cent of them (17 cases). We analysed several parameters from each case: first, those parameters significantly associated with stomal recurrence were detected, and secondly, a logistic regression analysis was done. Three factors were found independently related to stomal recurrence: T-staging, site of the primary tumour and prior tracheostomy. Together with a review of the literature, we discuss our findings and a proposal for management of the high risk patient.

Is emergency laryngectomy a waste of time?

Introduction: Patients whor present with airway obstruction due to carcinoma of the larynx may be managed by tracheotomy followed by definitive tumor surgery at a later date. An alternative is emergency laryngectomy, defined as total laryngectomy performed within 24 hours, for a previously untreated and undiagnosed malignancy. In this study, we compare and contrast the outcome of 13 patients managed by tracheotomy and delayed laryngectomy to another group of patients, previously reported, managed by emergency laryngectomy. Materials and Methods: Stridor due to malignant laryngeal neoplasm was treated by tracheotomy and delayed definitive laryngectomy in 13 patients. In every case, the tracheostomy site was removed with a surgical specimen. A comparison of the survival data was performed with earlier reported series of 13 emergency laryngectomies using the Wilcoxon log rank method. Results: All patients were followed for a minimum of 24 months. Seven patients underwent postoperative radiotherapy. Two of these patients (15%) developed peristomal recurrence at 6 and 22 months respectively. Both died of disease. Six patients from each group survived disease free for a minimum of 24 months. No significant correlation was found between the time delay of definitive surgery and survival ( P > .5). Discussion: This series suggests that emergency laryngectomy offers patients no survival advantage. Emergency laryngectomy does, however, have several disadvantages. These include the necessity to rely on frozen section analysis, the difficulty in obtaining expert anesthetic support, and the inability to provide thorough and complete nutritional and metabolic work up before major surgery. Finally, the psychologic aspects of radical surgery for patient and family cannot be adequately addressed. We conclude that stomal recurrence is as much a function of extensive disease at presentation as of preliminary tracheotomy. Emergency laryngectomy is not a superior treatment modality and offers no particular survival advantage.

Anterior mediastinal tracheostomy with and without cervical exenteration

Anterior mediastinal tracheostomy (AMT) facilitates resection of stomal recurrences after laryngectomy for carcinoma and tumors involving the cervicothoracic trachea and esophagus. Erosion of the innominate artery has been reported as a frequent major complication of AMT, and routine prophylactic division of the innominate artery with AMT has even been advised. Forty-four patients underwent AMT, 10 as an isolated procedure (for stomal recurrence [5], laryngeal carcinoma [1], or benign stenosis after laryngectomy [4]) and 34 with concomitant cervical exenteration (laryngopharyngoesophagectomy) for laryngeal, thyroid, or cervicothoracic esophageal malignancies. Transposition of the remaining tracheal stump beneath and to the right of the innominate artery to eliminate tension on the vessel was carried out in 14 patients (32%). Postoperatively, anastomotic leaks complicated nine of 31 pharyngogastric anastomoses. Iatrogenic hypoparathyroidism occurred in 10 patients. All six hospital deaths (14%) occurred in patients undergoing AMT with cervical exenteration, not isolated AMT. There was only one instance of innominate artery erosion. Survival was related to the pathology for which AMT was performed. Anterior mediastinal tracheostomy is a valuable adjunct in the treatment of select patients with malignancies of the cervicothoracic trachea and esophagus, and with attention to operative detail, innominate artery erosion should rarely, if ever, complicate the operation. Prophylactic division of the innominate artery with AMT is unnecessary.

Laryngeal chondrosarcomas: a clinicopathologic study of 11 cases, including two "dedifferentiated" chondrosarcomas.

Laryngeal chondrosarcomas are uncommon, and those that contain a distinct, nonchondroid, high-grade spindle cell sarcoma (the so-called "dedifferentiated" chondrosarcoma or chondrosarcoma with additional malignant mesenchymal component [CAMMC]) are extremely rare. Laryngeal CAMMC merit special attention, as CAMMC in other sites portends a poor prognosis. Eleven patients with laryngeal chondrosarcomas are reported on; 2 of these patients had CAMMC. On follow-up, 3 of the 11 patients had recurrences. The first had recurrence 4 and 11 years after tumor enucleation; that patient died disease free 2 years after salvage total laryngectomy. The second had recurrence 2 years after partial laryngectomy and was lost to follow-up after salvage total laryngectomy. The last patient recurred 13 years after partial laryngectomy and underwent salvage total laryngectomy; that patient was one of the two who developed CAMMC, and he also developed stomal recurrence of the "dedifferentiated" component 3 years after total laryngectomy. The other 8 patients are disease free after partial laryngectomy (6) or total laryngectomy (2) 10 months to 12 years later (mean: 51 months). This includes the 1 other patient with CAMMC, who is disease free 60 months after total laryngectomy. Laryngeal CAMMC has been shown, in at least one of the two patients, to be associated with a poor outcome. Patients with recurrent laryngeal chondrosarcomas do not have a poorer outcome after salvage total laryngectomy. The authors advocate partial laryngectomy if technically feasible.

Emergency laryngectomy

From 1974 to 1990, 31 patients underwent emergency laryngectomy for airway obstruction due to laryngeal carcinoma, in an effort to avoid the complication of stomal recurrence. This group of patients had a greater proportion of multiregional tumours (35 per cent vs 13 per cent) than a comparison group of elective laryngectomies. In other respects the two groups were similar. Early post-operative mortality (6.5 per cent vs 3 per cent), stomal recurrence rates (4.2 per cent vs 4.8 per cent) and survival (53 per cent vs 55 per cent) were not significantly different between the emergency laryngectomy group and the comparison group undergoing elective laryngectomy.

An irldium-192 applicator for the treatment of stomal recurrence following tracheostomy for subglottic carcinoma

A 45-year-old man presented with a left-sided posterior triangle neck node and a history of sore throats for a year. At the time of presentation he had no other symptoms. An examination under anaesthetic was undertaken and revealed no abnormality of the larynx or pharynx but a suspicious area was seen in the nasopharynx. Biopsy of this region, however, was normal. Histology of the nodes dissected from the left side of the neck revealed anaplastic carcinoma and the appearances were in keeping with a primary from the nasopharynx or bronchus. Tonsillar biopsy was normal. On clinical judgment the nasopharynx was thought to be the most likely primary site and so the patient was treated with radical radiotherapy to the neck and nasopharynx. The neck was treated with an anterior beam of MV photons from a linear accelerator with midline shielding (2 cm wide, 6 cm thick) to redbce the dose to the spinal cord (Ho, 1978).

Post-laryngectomy stomal recurrence: tumour implantation or paratracheal lymphatic metastasis?

In the treatment of obstructing laryngeal cancer, an association has often been noted between emergency tracheotomy for airway relief and subsequent post-laryngectomy stomal recurrence. It is however unclear whether this is due to tumour implantation in the tracheotomy track, or paratracheal lymph node metastasis. To investigate the pathophysiology of stomal recurrence, the recurrence rate and clinical outcome of 26 cases of T3N0M0 glottic cancer treated with emergency tracheotomy and subsequent laryngectomy were analysed, and compared with 65 stage-matched cases treated with laryngectomy alone. Analysis shows the 'emergency tracheotomy' group to have a very poor prognosis with a higher incidence of recurrence at the stoma, and also in the regional lymph nodes. These findings suggest that paratracheal lymph node metastasis is an important mechanism in the development of stomal recurrence and thus has considerable implications for the prevention of such a recurrence following laryngectomy in the patient presenting with malignant airway obstruction.

Recurrence after radiotherapy for glottic carcinoma

A series of 478 patients with T1-3N0 glottic carcinoma treated by irradiation is presented. Of these patients, 320 were previously untreated, whereas 158 patients were referred for treatment of a recurrence after receiving radiotherapy elsewhere. The primary recurrence rate in the previously untreated patients was 10%. The rate was higher in T2 and T3 tumors, poorly differentiated tumors, and in patients who were in poor general condition. Over 80% of the recurrent tumors were Stage pT3 or pT4, whereas 12% of total laryngectomy specimens showed necrosis only with no evidence of tumor. The necrosis rate in previously untreated patients was 1% for T1 tumors, 4% for T2 tumors, and 3% for T3 tumors. Of all tumors, 60% were transglottic when they recurred, whereas only 29% were confined to the glottis at recurrence. Histologic diagnosis had a high sensitivity but a low specificity, indicating that a negative histologic report is unreliable. Of patients with a recurrent primary tumor, 13% were untreatable. The 5-year survival after a primary recurrence was 39%, and the main prognostic factors were sex, T stage at recurrence, and time to recurrence. Of patients available for follow-up at 5 years 49% were alive with a larynx, 5% were alive without a larynx, 13% were dead of the original cancer, and 33% had died of other causes. In those suffering a primary recurrence, the commonest cause of death was a subsequent lymph node metastasis, followed in order of frequency by stomal recurrence and recurrence in the pharyngeal remnant. The hospital mortality rate after laryngectomy was 3%, and 30% of patients undergoing laryngectomy developed a pharyngocutaneous fistula. The recurrence rate in lymph nodes was 14% at 5 years, general condition and T stage being the only significant predictors of recurrence. Only 17% of patients had small (N1) nodes by the time the diagnosis of cervical lymph node recurrence was made, and 27% of all patients were unsuitable for treatment. Host, tumor factors, and time to recurrence were not significant predictors of survival after node recurrence. The survival rate 5 years after node recurrence was 16%, and the main cause of death in those who died was uncontrolled disease in the neck. The hospital mortality after salvage neck dissection was 4.7%.

Stomal recurrence after laryngectomy: Interrelated risk factor study

This study was designed to identify pathogenic factors in recurrent carcinoma at the tracheal stoma. The charts of 444 patients with laryngeal cancer who were treated surgically between 1976 and 1988 revealed stomal recurrence in 15 (3.4%). Eighty percent of the patients with stomal recurrence had tumors in the subglottis. In comparison to patients with different sites involved this was significant (p less than 0.001). Other variables examined and analyzed included primary stage, previous treatment, neck pathologic status, neck treatment, age, sex, postoperative adjunctive therapy, and timing of tracheotomy. Tumor involvement of the subglottis is the single most important variable in stomal recurrence of carcinoma. Previous conservation laryngeal surgery and preoperative/emergency tracheotomy are not related to stomal recurrence of carcinoma. Mean length of survival for patients with stomal recurrence of carcinoma in our series was 8.9 months. Two patients were successfully treated with extensive surgical resection. The dismal prognosis of stomal recurrence of carcinoma suggests that management of this condition should focus on prevention. Treatment of patients with tumors of the subglottis should include attention to the paratracheal region and superior mediastinum, in conjunction with laryngectomy immediately after initial diagnosis.

The Value of Manubrial Resection in Avoiding Stomal Recurrence

At the 32nd annual meeting of the American Society for Head and Neck Surgery, Palm Beach, Fla, April 30, 1990, Sir Donald Harrison presented a treatment rationale for patients at high risk for stomal recurrence. Harrison reiterated that the prevention of stomal recurrence is much more feasible than treatment of this devastating problem. He further stated that the patients with cricoesophageal and subglottic cancers are at high risk for stomal recurrence based on clinicopathologic evidence of residual disease in the trachea, tracheoesophageal wall, or metastasis in the paratracheal lymph nodes of surgical specimens. The manubrium and clavicular heads at times hamper the surgeons' ability to obtain an inferior margin, and to adequately clear the paratracheal and upper mediastinal nodes. Harrison reported on his series of 71 manubrial resections for the prevention of stomal recurrence. His patients were divided into three groups based on disease location or the need for a gastric

Stomal recurrence: A separate entity?

Uncertainty exists concerning the exact aetiology of stomal recurrence following laryngectomy, although it is generally agreed that, when present, the prognosis is very poor. Fourteen cases of stomal recurrence were compared with 15 cases of other types of aggressive recurrence in the neck, for factors implicated in stomal recurrence. Similarities exist between the two groups and, although stomal recurrence has a greater association with subglottic tumour, this difference is not statistically significant. The possible mechanisms of recurrence are discussed, particularly in relation to aggressiveness, and it is concluded that factors involved in aggressive recurrences are similar. Stomal recurrence can be considered part of a group of aggressive neck recurrences associated with more advanced disease prior to laryngectomy.

Emergency laryngectomy

Emergency laryngectomy is a laryngectomy carried out for malignant obstruction of the upper airway within 24 h of admission. This combines relief of the obstruction with definitive primary cancer surgery, and is thought to reduce the risk of post-laryngectomy stomal recurrence. During a 5-year period, 13 patients with upper airway obstruction from squamous cell carcinoma were treated in two departments by emergency laryngectomy. Total laryngectomy was carried out after the diagnosis of squamous cell carcinoma of the larynx (n = 11), or piriform fossa (n = 2), had been confirmed by laryngoscopy and frozen section biopsy. The actuarial 5-year survival was 47%, and no patient in this series developed stomal recurrence. The management of the airway obstruction, and the post-laryngectomy complications, did not differ from those encountered with more conventional treatment. Our experience with this approach suggests that emergency laryngectomy is a satisfactory method of managing airway obstruction due to squamous cell carcinoma of the larynx.

1989 Ogura memorial lecture: mediastinal dissection.

The mediastinal dissection was introduced in 1962 to manage an otherwise uniformly fatal problem in head and neck oncology: stomal recurrence of laryngeal, squamous cell cancer. The morbidity and mortality rates continued to be high and the survival rates low, but they were an improvement over those of other treatment plans. Since then, refinements of the ablative techniques and major advances in the reconstructive techniques have significantly decreased morbidity and mortality rates. The most recent data indicate a 45% survival rate at 42 months. It is evident that early diagnosis and staging of stomal recurrences will yield successful results. Because the mediastinal dissection operation is now safe, it should be applied more liberally in head and neck oncology situations such as subglottic extension of laryngeal cancer, advanced thyroid cancers, cervical esophageal and tracheal cancers, and all head and neck tumors with low-nodal disease.

Stomal recurrence following total laryngectomy--a clinicopathological study

A clinicopathological study of 10 cases of stomal recurrence following total laryngectomy treated at Kurume University Hospital from 1971 to 1986 was completed. The results of this study are summarized as follows: 1) The frequency of stomal recurrence was 5.8%. 2) Of these 10 cases, 3 cases were supraglottic (3%), 5 cases were glottic (7%), and 2 cases were subglottic (29%) carcinomas. The incidence of stomal recurrence was higher in subglottic carcinomas. 3) Nine cases out of 10 extend to the subglottic region. 4) The incidence of stomal recurrence was higher in emergency tracheostomy case. 5) Average of period from total laryngectomy to stomal recurrence was 9.7 months. 6) It is suggested that the cause of stomal recurrence is metastasis to the paratracheal lymphnode. 7) In order to prevent stomal recurrence, it is important to dissect paratracheal soft tissues bilaterally in high risk cases. 8) With regard to treatment, it is better to remove surgically the tumor and paratracheal soft tissues as completely as possible and to do postoperative radiation.

Prevention of stomal recurrence in patients requiring emergency tracheostomy for advanced laryngeal and pharyngeal tumors.

Since 1976, patients requiring emergency tracheostomy for advanced laryngeal and hypopharyngeal cancer at the University of Cincinnati have been treated with a short course of prelaryngectomy radiation in an attempt to decrease the incidence of stomal recurrence. Twenty-one patients were treated after emergency tracheostomy with a course of radiation that usually consisted of 20 Gy in five fractions followed by laryngectomy 1 or 2 days later. Most patients also received postoperative radiotherapy of some type. The follow-up of 18 evaluable patients revealed only two (11%) stomal recurrences--a quite acceptable rate for this high-risk population. Overall, however, local recurrences were seen in ten patients (56%), which is higher than reported in most series of similar tumors. The most likely explanation for this seems to be that the short course preoperative radiation prevented the administration of adequate postoperative radiation for residual disease, which was usually present. An alternative treatment policy would be a planned course of moderate- to high-dose postoperative radiation, which could sterilize tumor in the entire locoregional area including the stoma.

"Emergency" laryngectomy and stomal recurrence.

The data on 281 patients who underwent surgical therapy for laryngeal carcinoma from 1976 through 1984 were reviewed, revealing 16 patients who presented with an impending obstruction of the airway that was treated by an "emergency" laryngectomy. A review of the patients in our series did not reveal any serious complications from the procedure and it has allowed effective management of these advanced neoplasms. In addition, 10 patients who developed peristomal recurrences were reviewed. Preoperative factors such as location of lesion, antecedent surgery, and previous radiation therapy were assessed and compared to the patients who underwent "emergency" laryngectomy in an attempt to further define risk factors involved in peristomal recurrence. A strong association with subglottic extension was noted. Also associated in this review was antecedent full-course radiation therapy.