Subglottic Carcinomas Research Articles

The Application of Epiglottic Laryngoplasty after Partial Laryngectomy

Objectives: Observe the applied value of epiglottis in laryngeal function reconstruction after partial laryngectomy. Methods: From April 1997 to December 2008, there were 295 patients with laryngeal carcinomas who were operated on in our department. There were 40 patients who had partial laryngectomy and laryngeal function was reconstructed using epiglottis with or without other materials. The 40 cases were followed up and the oncologic and functional results were retrospectively analyzed. We calculated the 3- and 5-year tumor-free survival rates and evaluated the rehabilitation of laryngeal function. Results: The 3- and 5-year tumor-free survival rates were 82.9% and 75.7%, respectively. All of the patients with supraglottic carcinoma had tumor-free survival; in the 3 patients with subglottic carcinomas, only 1 patient had tumor-free survival for 5 years; in the 34 patients with glottic carcinomas, 6 patients died, and 1 patient with local recurrence had a total laryngectomy. The total decannulation rate was 90%. Thirty-nine patients rehabilitated normal peroral feeding. The mean time of removal of the nasogastric tube was 15.7 days. In the 40 cases, voice quality was good in 6 patients with a little hoarseness, 2 were worse, having only a whispered voice, and the others were moderate; the rate of vocal satisfaction was 95%. Conclusions: Using the epiglottis with or without other materials to reconstruct laryngeal function after partial laryngectomy is a useful alternative to total laryngectomy in laryngeal cancers, especially in selected advanced cases which improve the quality of life. The epiglottis is one of the ideal materials in laryngoplasty after partial laryngectomy.

The prognostic value of tumor-stroma proportion in laryngeal squamous cell carcinoma

Tumor-stroma proportion of tumor has been presented as a prognostic factor in some types of adenocarcinomas, but there is no information about squamous cell carcinomas and laryngeal carcinomas. Five digital images of the tumor sections were obtained from 85 laryngeal carcinomas. Proportion of epithelial tumor component and stroma were measured by a software tool, allowing the pathologists to mark 205.6 μm2 blocks on areas as carcinomatous/stromal, by clicking at the image. Totally, 3.451 mm2 tumor areas have been marked to 16.785 small square blocks for each case. Median follow up was 48 months (range 3-194). The mean tumor-stroma proportion was 48.63+18.18. There was no difference for tumor-stroma proportion when tumor location, grade, stage and perinodal invasion were considered. Although the following results were statistically insignificant, the mean tumor-stroma proportion was the lowest (37.46±12.49) for subglottic carcinomas, and it was 52.41±37.47, 50.86+19.84 and 44.56±16.91 for supraglottic, transglottic and glottic cases. The tumor-stroma proportion was lowest in cases with perinodal invasion and the highest in cases without lymph node metastasis (44.72±20.23, 47.77±17.37, 50.05±17.34). Tumor-stroma proportion was higher in the basaloid subtype compared with the classical squamous cell carcinoma (53.76±14.70 and 48.63±18.38 respectively). The overall and disease-free survival analysis did not reveal significance for tumor-stroma proportion (p=0.08, p=0.38). Only pathological stage was an independent factor for overall survival (p=0.008). This is the first series investigating tumor-stroma proportion as a prognostic marker in laryngeal carcinomas proposing a new method, but the findings do not support tumor-stroma proportion as a prognostic marker.

Distribution of mucins and antimicrobial substances lysozyme and lactoferrin in the laryngeal subglottic region

The subglottic region of the larynx is of high clinical relevance with regard to infections and malignancies. Little is known about the distribution of mucins and antimicrobial substances in this area. In this study, we have investigated the mucin distribution in the normal subglottis of the larynx. Moreover, we analysed the expression of lysozyme and lactoferrin in this area. Therefore, the subglottic region of 34 larynges was investigated immunohistochemically with different antibodies to mucins and antimicrobial substances. The epithelium reacted positive with antibodies to mucins MUC1 (34/34), 5AC (26/34), 5B (10/34), 7 (8/34), 8 (10/34) and 16 (19/34); submucosal glands were positive to mucins MUC1 (34/34), 5B (10/34), 7 (8/34), and 16 (19/34); high columnar epithelial cells and serous parts of subepithelial seromucous glands were also positive for lysozyme (34/34) and lactoferrin (34/34). The results show that human subglottic epithelium and subepithelial submucosal glands produce a broad spectrum of mucins that is almost comparable with that in other areas of the respiratory tract. We hypothesize that the mucin diversity of the subglottis has an impact on positive functional consequences during vocal production and antimicrobial defence. This antimicrobial defence is supported by synthesis and secretion of antimicrobial substances such as lysozyme and lactoferrin. Moreover, knowledge of the observed distribution pattern of mucins in the subglottis can be a useful tool for a classification of subglottic laryngeal carcinomas.

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.

A Phase II Study of Concomitant Chemoradiotherapy for Laryngeal Carcinoma Using Carboplatin

Purpose: We conducted a phase II study of concomitant chemoradiotherapy with carboplatin for laryngeal carcinoma. Materials and Methods: Sixty-four patients with stage II–IV (stage II, 36; III, 19; IV 9) laryngeal carcinoma were treated with concomitant administration of carboplatin (CBDCA) during radiotherapy (CRT group) between 1991 and 1994. There were 36 supraglottic, 25 glottic, and 3 subglottic carcinomas. Patients with stage II and stage III–IV received intravenous CBDCA of 100 mg/m² and 120 mg/m² once a week, respectively. Tumor response was assessed at 40 Gy in 16 fractions to select the patients suitable for total laryngectomy or radical radiotherapy of 65 Gy in 26 fractions in 6.5 weeks. The treatment results were compared with the historical control consisting of 56 patients consecutively treated from 1988 to 1990 without chemotherapy (RT group). The two studies were comparable with regard to patient characteristics, including age distribution, gender, tumor location, size, and clinical stage. Results: The actuarial 5-year survival rate was 80.3% for the CRT group and 81.3% for the RT group. A favorable response (complete response or partial response) at 40 Gy was observed in 87.5% of the patients of the CRT group and in 62.5% of the patients of the RT group (χ² = 7.566, p < 0.01). The actuarial 5-year larynx preservation rate for the CRT group (75%) was significantly higher than that for the RT group (57%) in patients with T₂ supraglottic carcinoma (p < 0.05). There was no difference in the larynx preservation rate between the two treatment arms for any T stage of glottic carcinomas. Conclusion: CRT using carboplatin improved the tumor response at 40 Gy and consequently achieved a higher larynx preservation rate for T₂ supraglottic carcinoma. A clinical randomized trial is indicated to certify the findings of this phase II study.

Management of the thyroid gland with laryngectomy for cT3 glottic carcinomas.

Is routine hemithyroidectomy justified in laryngectomy for laryngeal carcinoma? Hemithyroidectomy with laryngectomy causes hypothyroidism in up to 25% of patients, and if combined with radiotherapy, in up to 70%. In this review of 102 total laryngectomies with routine hemithyroidectomy for cT3 glottic carcinoma, laryngeal carcinoma involved the thyroid gland in two. Both had subglottic tumour extension. The tumour approached within 3 mm of the thyroid capsule in seven. It is proposed that thyroidectomy should be performed only in selected laryngeal carcinomas. Intraoperative assessment of the thyroid gland should determine the need for thyroidectomy in glottic and transglottic carcinomas. Carcinoma invasion of the thyroid gland should be confirmed by frozen section before proceeding to thyroidectomy. In the absence of thyroid gland involvement, both thyroid lobes may be preserved. Total thyroidectomy should be performed if the thyroid gland has been invaded. Total thyroidectomy should be routinely performed with subglottic carcinomas.

439 An epidemiological study of squamous cell carcinomas of head and neck region

Of 1518 patients admitting to Department of Radiation Oncology from 1978 to 1994 with cancers of head and neck region, medical reports of 1293 patients with squamous cell carcinomas were retrospectively evaluated. The patients were classified according their age, sex, tumor localization and stage of tumor at presentation. Staging was performed according to TNM classification by American Joint Commitee (AJC). 1181 patients (91.3%) were male and 112 (8.7%) were female, with a male:female ratio of 10.5:1. The tumor was localized in larynx in 919 (71.1%) patients, nasopharynx in 131 (10.1%), oral cavity in 59 (4.6%), lip in 54 (4.2%), oropharynx in 33 (2.5%), hypopharynx in 31 (2.4%), paranasal sinuses in 20 (1.5%), external auditory canal in 17 (1.3%) and nasal cavity in 5 (0.4%) and other regions in 24 (1.9%) patients. Peak incidence was similar for all localizations and was observed in the fifth decade. Larynx cancers were most commonly localized in the supraglottic region (59.5%), followed by glottic (39.7%) and subglottic (0.8%) regions. Seventy-four percent of glottic larynx carcinomas were either stage I or II. Invasion of cartilage was relatively more common with supraglottic carcinomas than with glottic and subglottic carcinomas. Male:female ratio for larynx carcinomas was 29.6: 1.

Clinical study of subglottic carcinoma

Recently, therapy for laryngeal carcinoma has been becoming established, particularly in the early stage. The prognosis of laryngeal carcinoma is said to be better than that of other head and neck carcinomas. Laryngeal carcinoma is divided into 3 subtypes, supraglottic, glottic and subglottic, according to origin. We analyzed the subglottic carcinomas diagnosed and treated in our department between 1972 and 1990. During that period we treated 515 cases of laryngeal carcinoma, 204 cases of the supraglottic type, 284 cases of the glottic type, and 27 cases (5.2%) of the subglottic type. The 5-year survival rate in subglottic carcinoma was 44% (T1: 83%, T2:55%, T3: 17%, T4: 0%), worse than in the other types of laryngeal carcinoma. We think that there were 2 main reasons for the worse prognosis. The first was their high rate of local recurrence after radiation therapy particularly in the early stage. Although 15 T1 and T2 patients who received full dose (65Gy) radiotherapy had a complete response, 8 patients developed local recurrence. The results of the salvage operation were good in T1 cases, but were followed by death because of metastasis or second recurrence in 2 of the 3 T2 patients. The second reason for the worse prognosis appeared to be metastasis in the advanced cases. Five (50%) T3 and T4 patients developed metastasis to the lung, mediastinum and cervical lymph nodes, resulting in death. Thus, we believe that the main therapy for subglottic carcinoma, except T1, should be surgery to obtain a better outcome, and that adjuvant chemotherapy after irradiation or neck (paratracheal) dissection with total laryngectomy should be performed in advanced cases.

Improvements observed in care and outcome in carcinoma of the larynx

The 1978 Patterns of Care Studies (PCS) survey of carcinoma of the larynx reviewed the process (pre-treatment evaluation and treatment) and outcome of 521 patients. When compared to results from the 1973 PCS survey, several important changes have been observed. The use of surgery in conjunction with radiation therapy (RT) increased in Stage III cases from 〈30% to 60%〉 and in Stage IV cases from 48% to >70%. This change in therapy was associated with a decline in locoregional failure in this patient group. Among Stage I and II supra- and subglottic carcinomas, an improvement in 3-year local tumor control (Stage I: 78 to 100% and Stage II: 54 to 74%) and overall freedom from recurrence (Stage I: 78 to 100% and Stage II: 45 to 73%) was seen over this 5-year period with no identifiable change in process for this subgroup. Also noted was an improvement in the freedom from recurrence rate for Stage III and IV patients receiving treatment at facilities with low process scores. The 1978 PCS survey confirmed the presence of superior patient outcome in several subgroups and the relationship of this improvement to patient process.

喉頭癌の初回治療方針

For the past ten years, the choice of treatment modalities for laryngeal carcinoma has depended not only on the T-stage but also on the cancer characteristics including the growing type, anatomical location and extension, and depth of invasion. A total or an extended total laryngectomy has been indicated for the following lesions; 1) glottic T2 invading the subglottic region (especially that of anterior type), T3 and T4, 2) supraglottic T2 invading the ventricle, the vocal cord and/or the anterior commissure, T3 and T4, 3) transglottic carcinomas and 4) subglottic carcinomas. To prevent local recurrence in case of (extended) total laryngectomy, it is important to understand the feature of tumor extension outside of the larynx and confirm the extent of the lesion directly by opening the larynx at the midline of the cricoid lamina.A total of 735 patients were treated at our hospital between 1979 and 1988. Forty-six percent of the patients received radiation (60-70 Gy) whereas the remaining patients underwent laryngectomy (partial laryngectomy in 4%, total laryngectomy in 50%). Only two local recurrences were observed in the totally laryngectomized patients. The overall 5-year cumulative survival rate was 72.4 % (cause specific 87.3%, minimum follow up interval : 5 years, n=319). The cumulative survival rates for stage III and IV lesions were 62.6%, and 55.6% for glottic, 62.5% and 51.2% for supraglottic, and 65.5% and 35.9% for transglottic lesions, respectively.

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.

A Histopathological Study of Carcinoma of the Larynx

Fifty-one laryngectomy specimens were histopathologically studied in serial sections. The incidence of thyroid cartilage invasion was 10% in supraglottic, 48% in glottic, and 67% in subglottic carcinomas. The incidence of cricoid cartilage invasion was 0% in supraglottic, 22% in glottic, and 33% in subglottic carcinomas. The sites of cartilage invasion were the anterior commissure portion and an ossified lower portion of the thyroid cartilage, and an ossified upper portion of the cricoid cartilage. Fixation of the vocal fold in glottic carcinoma was accounted for by carcinomatous invasion into three-fourths or more of the thyroarytenoid muscle. Impairment of the vocal fold movement was accounted for by carcinomatous invasion into three-fourths or less of the thyroarytenoid muscle. Fixation of the vocal fold in supraglottic carcinomas was accounted for by a massive carcinomatous invasion around the upper aspect of the arytenoid cartilage.

Aspects on Laryngeal Cancer Based on Whole Organ Sections

Whole organ sectioning of laryngectomy specimens has been applied since quite a few years to increase our knowledge of the histopathological behavior of laryngeal carcinoma. The laboratory techniques have been successively refined with shortening of the processing time and with improved histological results. The larynx may be cut in the coronal, sagittal or in the transverse plane, which has become more actual for comparison between computed tomograms and histopathological findings. The growth and spread of laryngeal cancer is determined by the site of origin. Glottic carcinomas often invade the thyroid cartilage in the anterior commissure area and extend outside the larynx through cartilage or by extending subglottically and then through the crico-thyroid membrane. More extensive glottic carcinomas with supra- and/or subglottic extension may spread laterally through the crico-thyroid space. This way of spread is very characteristic for tumors surrounding the laryngeal ventricle--"transglottic carcinomas." Supraglottic carcinomas show a high tendency to invade the pre-epiglottic space. Despite an advanced size they tend to be confined to the supraglottic region, but may especially when ulcerated extend down to the glottic region in the anterior midline. Primary subglottic carcinomas are rare but tend to be advanced when diagnosed, having a circumferential growth with extension up into the vocal cord muscles. They may invade the laryngeal framework and spread outside the larynx through the crico-thyroid membrane. By using the whole organ sectioning technique we have gained further knowledge of the strength and weaknesses of our clinical and radiological diagnostic methods and we have a possibility to compare the radiographic findings with the histopathological sections.(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinoma of the Larynx

A retrospective review of 252 patients of carcinoma of the larynx treated for the first time at Kurume University Hospital from 1971 to 1980 was completed. Two hundred and forty-four patients underwent curative treatments while 8 were palliatively treated or referred to other hospitals. The results of this retrospective studies are summarized as follows: (1) In 244 patients of curative treatments, 5-year cummulative survival rate calculated by the actuarial method was 69.4%. (2) There were 88 supraglottic, 150 glottic and 6 subglottic carcinomas. Five-year cumulative survival rate for each of these groups was 54.8%, 77.9% and 50.0%, respectively. (3) The more advanced the disease was, the lower the survival rate. (4) Of 67 deaths in the curative treatment group, the cause of death was primary lesion in 3, neck metastasis in 12, distant metastasis in 14, unknown in 2 and intercurrent disease in 36. (5) There was an appreciable improvement in the results of treatment in the era between 1971 and 1980 compared to the era between 1960 and 1970 in our department.