Treatment Of Advanced Laryngeal Carcinoma Research Articles

Linear stapler closure of the pharynx in laryngectomy: our experience (endoscopic closed technique)

Background: Total laryngectomy is the surgical treatment for advanced laryngeal carcinoma. Recently it’s used the linear stapler to treat laryngeal carcinoma. The pharyngeal repair is performed with layered sutures, or using a linear stapler device, using technique of closed pharyngoplasty with linear stapler, by laryngoscope’s guide to see and to hook epiglottis through the trachea. Methods: We compared the results between total laryngectomy technique with conventional manual suture with needle and gut and closed technique adopted by our otolaryngology’s service with mechanical stapler (GIA) in advanced laryngeal carcinoma. We used a linear stapler Ethicon endo-surgery 90 mm (Proximate) with 76 titanium staples and an integrated scalpel (dimension open suture: 3.0 mm × 3.85 mm) and an endoscope (2.7 mm 0°). Results: We had an important reduction of surgical times, less immediate complications, reduction of length of stay in hospital with the gastric nose tube and reduction of general length of hospital stay. Conclusions: Comparing to the traditional technique, the use of mechanical sutures improve significantly: the surgical time, reducing the length of hospital stay, restoring the physiological oral nutrition and the time of removal of the gastric nose tube. Finally, we demonstrated the reduction in the incidence of complications such as fistula and postoperative fever.

Laryngeal cancer

Treatment of laryngeal carcinoma continues to evolve, and whereas there was a transition from total laryngectomy to chemoradiation in response to the Veterans Affairs study and Radiation Therapy Oncology Group (RTOG) 91-11, recent data suggest the role of partial laryngectomy must be revisited. Recent data have shown that laryngeal preservation does not equate with laryngeal function. Data are accumulating in support of operative management of advanced laryngeal carcinoma away from chemoradiation for select patients. In particular, supracricoid laryngectomy may be a viable option for intermediate and selected advanced laryngeal carcinoma while maintaining laryngeal function. The evolution of treatment for advanced laryngeal carcinoma is focusing treatment on maintaining locoregional control while also maintaining a functional larynx.

Preventing pharyngo‐cutaneous fistula in total laryngectomy: A systematic review and meta‐analysis

Concurrent chemoradiotherapy is the gold-standard nonsurgical organ-preservation treatment for advanced laryngeal carcinoma. Total laryngectomy (TL) is increasingly reserved for surgical salvage. Salvage surgery is associated with more complications than primary surgery. A systematic review and meta-analysis was undertaken to establish the impact of organ preservation protocols on pharyngo-cutaneous fistula incidence following TL, and to synthesize evidence on the role of "onlay" prophylactic tissue flaps in reducing this complication in salvage TL. The English language literature (January 1, 2000, to September 1, 2013) was searched, using PUBMED and EMBASE databases, for the terms "laryngectomy" and "fistula." Of 522 studies identified from database searches, 33 were included in the quantitative synthesis. Studies reporting fistula incidence following primary TL (PTL), salvage TL (STL), and STL with "onlay" flap-reinforced pharyngeal closure were included. Data were extracted by the first author (M.S.). Meta-analysis of fistula incidence was performed. PTL fistula incidence is 14.3% (95% CI 11.7-17.0), STL 27.6% (23.4-31.8), and STL with flap-reinforced closure 10.3% (4.6-15.9). Chemoradiotherapy is associated with a pooled fistula incidence of 34.1% (22.6-45.6), compared to 22.8% (18.3-27.4) for radiotherapy alone. Relative risk of fistula is 0.566 (0.374-0.856, P = 0.001) for STL with flap-reinforced closure compared to STL alone. The number needed to treat (NNT) to prevent one fistula is 6.05. Prophylactic flaps used in an "onlay" technique reduce fistula incidence in STL. Chemoradiotherapy increases fistula incidence more than radiotherapy alone. Prophylactic flaps should be offered in salvage cases after failed chemoradiation protocols.

Stapled closed technique for laryngectomy and pharyngeal repair

Total laryngectomy is a recognised treatment for advanced laryngeal carcinoma. Traditionally, pharyngeal repair is performed with layered sutures. We describe our experience with a technique of closed pharyngoplasty using a linear stapler device. Ten total laryngectomies were performed from July 2002 to July 2004, using an Ethicon TLC 75 linear stapler for pharyngeal closure. Data collected included age, sex, staging, endoscopic assessment, surgical margins and post-operative course (including complications and swallowing). Patients comprised eight men and two women. The mean age was 55.4 years. Six patients had stage T4 endolaryngeal carcinoma and four had stage T3. Four patients underwent pre-operative radiotherapy. Clear surgical margins were achieved in all patients. One patient developed a pharyngocutaneous fistula. Patients resumed oral intake at 48 hours, or at 72 hours if they had undergone pre-operative radiotherapy. Patients' mean hospital stay was seven days. This stapled closed technique for pharyngoplasty is efficient and eliminates the risk of wound contamination, thus theoretically reducing the risk of tumour seeding. In addition, we were able to commence patients on oral fluids at a mean of 48 hours after surgery. The mean hospital stay was seven days. We recommend this technique as an alternative for repairing the pharynx in patients undergoing total laryngectomy for endolaryngeal carcinoma.

Advanced carcinoma of the larynx: Results of surgery and radiotherapy without induction chemotherapy (1980–1985): A multivariate analysis

Purpose: Induction chemotherapy has been proposed in the case of advanced laryngeal cancer in order to preserve laryngeal function in those patietns who are complete responders. To clarify the treatment policies, a restrospective multicentric analysis of 116 patients with advanced carcinoma of the larynx treated by radical surgery and postoperative radiotherapy was carried out in order to evaluate prognostic factors for local control and survival.Methods and Materials: Between 1980 and 1985, 116 patients with Stage III squamous cell carcinoma of the larynx underwent radical surgery and postoperative radiotherapy with a curative intent. Treatments were very homogenous, and doses delivered were in the range of 50–65 Gy according to nodal involvement and surgical margins status.Results: The local recurrence rate and the local disease-free survival rate at 5 years were 22.5% and 76.3%, respectively. Actuarial survival at 5 years was 68.3% with 44 patients stil alive who no evidence of disease (NED) with more than 5 years follow-up. For both overall survival and relapse-free survival, cervical node involvement with capsular rupture was found to be the only significant adverse pronostic factor in univariate and multivariate analysis. No other parameter was predictive either for local recurrence or for survival.Conclusions: Local prognosis and survival depend largely on nodal involvement and capsular rupture while increasing doses of radiation strategy is likely to reduce the risk of local and nodal recurrence. Preservation of functional larynx is certainly an important goal to achieve when treating advanced carcinoma of the larynx, provided that local failure rate and survival be similar. In the unique randomized study previously published in the literature comparing radical surgery and postoperative radiotherapy to induction chemotherapy and radiotherapy, the local-regional failure rate was drastically increased in the chemotherapy arm. Other results from well-designed controlled studies are awaited before recommending systemic induction chemotherapy and larynx preservation in complete responders. On the other hand, testing synchronous or alternated chemotherapy vs. induction chemotherapy may address the pending questions about the optimal treatment of advanced laryngeal carcinoma.

Analysis of recurrence after surgical treatment of advanced laryngeal carcinoma.

The pattern of recurrences after surgical treatment of 276 patients with stage T3 and T4 laryngeal carcinoma was reviewed. Nodal recurrence was the commonest site and occurred mainly in patients with supraglottic and transglottic carcinoma. Distant metastasis was the second commonest site of recurrence, and the most distant metastases developed without locoregional recurrence. Local recurrence alone was uncommon in patients treated with primary surgery.

Radiotherapy of advanced laryngeal cancer using three small fractions daily

Since 1983, we have treated advanced (UICC stages III and IV) squamous carcinomas of the larynx by primary radiotherapy, using three small fractions a day, 3-4 h interfraction interval, 5 days per week. The early patients received doses per fraction of 1.5 Gy, and a total dose of approximately 70 Gy, given as a split-course over 6 to 7 weeks. While overall tumor control and laryngeal preservation was good, a number of severe late radiation reactions were seen. The schedule was then modified, with a reduction in the fraction size to 1.1 Gy, the total dose to 60 Gy, and the overall time to 4 weeks, with omission of the mid-treatment "split." Since 1986, we have treated 26 patients in this way. Acute reactions are brisk, but rapidly healing. Loco-regional control was achieved in 22 patients, only one of whom has relapsed to date, in a solitary node, salvaged by radical neck dissection. Four have died of uncontrolled loco-regional malignancy, and three of intercurrent disease while in clinical remission. No serious late morbidity has been observed in surviving patients, and vocal quality is good in the majority. These results suggest that this hyperfractionated and accelerated radiotherapy schedule may offer an acceptable nonsurgical, voice-preserving treatment for advanced laryngeal carcinoma; it can be used in a normally working radiotherapy department.

Pre-operative irradiation in the treatment of advanced laryngeal carcinoma.

Pre-operative irradiation in the treatment of advanced laryngeal carcinoma.