Supraglottic hemipharyngolaryngectomy for the treatment of T1 and T2 carcinomas of laryngeal margin and piriform sinus

Comparison of Survival Outcomes Between Larynx-Preserving Open Partial Pharyngectomy and Radiotherapy or Chemoradiotherapy in Patients with Hypopharyngeal Squamous Cell Carcinoma: A Single-Center Retrospective Analysis with Inverse Probability of Treatment Weighting Adjustments

BACKGROUND

There is a group of hypopharyngeal squamous cell carcinoma (HPSCC) patients for whom larynx-preserving open partial pharyngectomy (PP) and radiotherapy/chemoradiotherapy (RT/CRT) are indicated. We aimed to retrospectively evaluate the survival difference as there is no evidence directly comparing the two therapies.

METHODS

This study evaluated HPSCC patients who were initially treated by PP or RT/CRT at our institution between January 2007 and October 2019. Overall survival (OS), disease-specific survival (DSS), laryngectomy-free survival (LFS), and local relapse-free survival (LRFS) were evaluated. The main analyses were performed with inverse probability of treatment weighting (IPTW) adjustments. Sensitivity analyses compared hazard ratios (HRs) obtained with three models: unadjusted, multivariate Cox regression, and propensity score-adjusted.

RESULTS

Overall, 198 patients were enrolled; 63 and 135 underwent PP and RT/CRT, respectively. IPTW-adjusted 5-year OS, DSS, LFS, and LRFS rates in the PP and RT/CRT groups were 84.3% and 61.9% (p = 0.019), 84.9% and 75.8% (p = 0.168), 94.8% and 90.0% (p = 0.010), and 75.9% and 74.1% (p = 0.789), respectively. In the IPTW-adjusted regression analysis, PP was associated with a significant benefit regarding OS (HR 0.48, 95% confidence interval [CI] 0.26-0.90) and LFS (HR 0.17, 95% CI 0.04-0.77). The results obtained with the three models in the sensitivity analyses were qualitatively similar to those of the IPTW-adjusted models.

CONCLUSION

Despite the risk of bias related to unadjusted factors, our results suggest that PP is associated with significantly better OS and LFS compared with RT/CRT for HPSCC.

Current Therapeutic Strategies for Patients with Hypopharyngeal Carcinoma: Oncologic and Functional Outcomes

Hypopharyngeal cancer is usually diagnosed at an advanced stage and is associated with a high risk of recurrence and poor survival rates. Although they differ greatly in terms of prognosis, hypopharyngeal cancers are usually treated together with laryngeal cancers in clinical trials. Therefore, there are very few studies that focus specifically on patients with hypopharyngeal carcinoma. As a result, the therapeutic management of these patients is highly debated, and their clinical outcomes are poorly reported. The aim of this review is therefore to discuss the current therapeutic options in patients with hypopharyngeal carcinoma and their oncologic and functional outcomes. Patients with early-stage tumors can be treated either by conservative surgery (including transoral robot-assisted surgery) or by RT alone. However, most patients are diagnosed with locally advanced tumors that cannot be treated surgically without total laryngectomy. In this situation, the critical issue is to select the patients eligible for a larynx preservation therapeutic program. However, radical surgery with total laryngectomy still plays an important role in the management of patients with hypopharyngeal carcinoma, either as the primary treatment modality (T4 resectable primary tumor, contraindication to larynx preservation therapies) or, more commonly, as salvage treatment.

Oncological and functional outcomes of transoral laser surgery for hypopharyngeal carcinoma

BACKGROUND

Surgical resection or radiotherapy (RT) are standard approaches for early-staged hypopharyngeal squamous cell carcinoma (HPSCC). Transoral laser microsurgery (TOLMS) seems to provide good oncological and functional results with few local complications. The aim of our study was to analyze the outcomes of TOLMS, with or without neck dissection or RT, in the treatment of HPSCC in a tertiary referral center.

METHODS

A retrospective study was conducted in patients with early T-category (T1-T2) HPSCC treated by TOLMS.

RESULTS

A total of 34 patients were included in the study. The series includes 17 (50%) T1 and 17 (50%) T2 classified tumors. The 5-year overall survival and disease-specific survival rates were 51% and 66%, respectively, with a 5-year local control rate of 92%. All patients reassumed oral diet and none of them had a tracheostomy at the end of the follow-up.

CONCLUSIONS

TOLMS offers an effective treatment option in terms of oncologic control and function preservation in locally circumscribed HPSCC.

Second primary lung cancer following laryngeal cancer: retrospective study of incidence and multivariate analysis of risk factors in 209 patients

OBJECTIVE

To analyse the incidence of second primary lung cancer following treatment for laryngeal cancer and to identify risk factors for its development.

METHOD

Retrospective case series.

RESULTS

The five-year actuarial incidence of second primary lung cancer was 8 per cent (1.6 per cent per year). This was associated with a very poor median survival of seven months following diagnosis. Supraglottic tumours were associated with an increased risk of second primary lung cancer compared to glottic tumours in both univariate (hazard ratio = 4.32, p = 0.005) and multivariate analyses (hazard ratio = 4.14, p = 0.03).

CONCLUSION

Second primary lung cancer occurs at a rate of 1.6 per cent per year following a diagnosis of laryngeal cancer, and this is associated in a statistically significant manner with supraglottic primary tumour. The recent National Lung Cancer Screening Trial suggests a survival advantage of 20 per cent at five years with annual screening using low-dose computed tomography scanning of the chest in a comparable cohort to ours. These findings have the potential to inform post-treatment surveillance protocols in the future.

Treatment results of 99 patients undergoing open partial hypopharyngectomy with larynx preservation

Objective

Hypopharyngeal cancers frequently go undetected until advanced stages. However, recent advances in endoscopic technology have enabled earlier detection of hypopharyngeal cancer. We evaluated the effectiveness of larynx-preserving surgery for hypopharyngeal cancer.

Methods

We retrospectively analyzed 99 patients with hypopharyngeal squamous cell carcinoma who underwent partial hypopharyngectomy with larynx preservation between September 1992 and December 2009 at the National Cancer Center Hospital East. Of these, 91 patients underwent larynx-preserving surgery as initial treatment; eight patients underwent salvage surgery for recurrent disease after previous radiotherapy. Also, 9 of our patients had undergone previous radiotherapy in the head and neck for a different cancer. Before surgery, the TNM stage and tumor location was recorded. Free-flap reconstruction was performed in 60 patients, while the hypopharyngeal mucosa was closed without a free flap in 39 patients.

Results

The 5-year overall survival rate in our cohort was 66.9%, and 59 patients are currently alive without recurrence. Thirty-three patients died due to primary recurrence (n = 5), regional recurrence (n = 10), distant metastasis (n = 9), postoperative death (n = 1), and unrelated disease (n = 8). Laryngeal function could not be preserved in 19 patients, 2 of whom had undergone previous radiotherapy, and 7 of whom had undergone both previous radiotherapy and other salvage surgeries.

Conclusion

Partial hypopharyngectomy can preserve laryngeal function in patients with pharyngeal cancer with careful patient selection.

Oncological and Functional Evaluation of Open Conservation Surgery for Hypopharyngeal Cancer with/without Reconstruction

Objectives

Oncological and functional results of open conservation surgery for hypopharyngeal cancer have been desired.

Methods

We performed a chart review of 33 patients with hypopharyngeal cancer who underwent open conservation surgery. Oncological and functional results were evaluated in surgery with primary closure (Group A) and surgery with reconstruction (Group B). Postoperative functions were evaluated by interval to resumption of oral intake, Functional Outcome Swallowing Scale (FOSS) and Communication Scale (CS).

Results

Five-year disease-specific and overall cumulative survival rates by Kaplan-Meier method for all cases were 95.7% and 82.3%, respectively. Duration from surgery to full oral intake was 12 days in Group A and 14 days in Group B. FOSS rates were 83.3 in Group A and 95.5 in Group B. CS was 0 in both groups.

Conclusion

Oncological and functional results of open conservation surgery were comparable to those with transoral surgery and chemo/radiotherapy. Our technique represents a reliable treatment for hypopharyngeal cancer.

Early hypopharyngeal cancer treated with different therapeutic approaches: a single-institution cohort analysis

Purpose

Early hypopharyngeal squamous cell carcinoma (HPSCC) is a rarely diagnosed disease, for which the optimal treatment has not been defined yet. We assessed patterns of failure and outcomes in early HPSCC treated with various therapeutic approaches to identify its optimal treatment.

Materials and Methods

Thirty-six patients with stage I (n = 10) and II (n = 26) treated between January 1992 and March 2014 were reviewed. Patients received definitive radiotherapy (RT) (R group, n = 10), surgery only (S group, n = 19), or postoperative RT (PORT group, n = 7). All patients in both the R and PORT groups received elective bilateral neck irradiation. In the S group, 7 patients had ipsilateral and 8 had bilateral dissection, while 4 patients had no elective dissection.

Results

At a median follow-up of 48 months, the 5-year locoregional control (LRC) rate was 65%. Six patients had local failure, 1 regional failure (RF), 3 combined locoregional failures, and 2 distant failures. There was no difference in 5-year LRC among the R, S, and PORT groups (p = 0.17). The presence with a pyriform sinus apex extension was a prognosticator related to LRC (p = 0.01) in the multivariate analysis. Patients with a bilaterally treated neck showed a trend toward a lower RF rate (p = 0.08).

Conclusion

This study shows that patients with early stage HPSCC involving the pyriform sinus apex might need a tailored approach to improve LRC. Additionally, our study confirms elective neck treatment might have an efficacious role in regional control.

Primary radiotherapy for squamous cell carcinoma of the pyriform sinus

The objective of this study is to report the long-term outcomes of primary radiotherapy (RT) for patients with T1-T2 squamous cell carcinomas (SCC) of the pyriform sinus. Between November 1964 and March 2008, 135 patients with T1-T2 pyriform sinus SCC were treated with primary RT at the University of Florida. Adjuvant chemotherapy was employed in 21 patients (16 %) and 62 patients (46 %) underwent a planned neck dissection. Median follow-up was 3.5 years (range 0.2-24.7 years); median follow-up on living patients was 8.3 years (range 3.8-24.0 years). The 5-year outcomes were as follows: local control, 85 %; regional control, 81 %; local-regional control, 71 %; distant metastasis-free survival, 76 %; cause-specific survival, 62 %; and overall survival, 38 %. The 5-year local control rate was 88 % for T1 cancers and 84 % for those with T2 SCCs (p = 0.5429). Sixteen patients (12 %) experienced severe late complications. Primary RT results in a high probability of cure with a relatively modest risk of severe late complications for patients with T1-T2 SCCs of the pyriform sinus.

Conservation surgery for hypopharyngeal cancer: changing paradigm from open to endoscopic

CONCLUSIONS

Endoscopic laser microsurgery (ELM) provides comparable oncological outcomes, and improved functional recovery and laryngeal preservation compared with open partial laryngopharyngectomy (OPLP) in patients with early squamous cell carcinoma of the hypopharynx (HPSCC). The use of open surgery is declining. The outcome of the study provides evidence-based recommendations for surgical choices in HPSCC treatment. However, it is not conclusive without a larger prospective study.

OBJECTIVES

To compare the functional and oncological results of ELM and OPLP in HPSCC and examine surgical trends.

METHODS

From 1990 to 2008, 53 HPSCC patients undergoing ELM (n = 25) and OPLP (n = 28) were included. Functional recovery, oncological results, and laryngeal preservation rate were analyzed.

RESULTS

Patients who underwent ELM demonstrated a shorter decannulation period (7 vs 11 days, p = 0.010), time using a nasogastric tube (7 vs 16 days, p = 0.043), and hospitalization stay (12 vs 22 days, p = 0.0061) than those who underwent OPLP. The 3-year overall and disease-specific survival rates were comparable between ELM and OPLP (79% vs 64%, p = 0.151, and 83% vs 71%, p = 0.320, respectively). The ELM patients had better laryngeal preservation (92% vs 71%, p = 0.048). The number of OPLPs performed has decreased since 2000 (68% before vs 32% after, p < 0.0001).

Role of surgery in the management of head and neck cancer: a contemporary view of the data in the era of organ preservation

OBJECTIVE

Review of the literature on the role of surgery in the management of head and neck cancer in the era of organ preservation.

METHOD

Literature search based on the essential practice guidelines set out by the US National Comprehensive Cancer Network.

RESULTS

Despite the increasing popularity of non-surgical treatment options, the surgeon remains a key figure in the multidisciplinary head and neck cancer team, along with the radiation oncologist, the medical oncologist and the speech and swallowing therapist. Even when organ preservation is successful, early and late toxicity may cause serious complications, including laryngeal dysfunction with a 'frozen larynx'. When organ preservation fails, salvage surgery is often associated with increased complications and reduced survival.

CONCLUSION

There is a definite need to apply more rigorous standards to the use of organ preservation strategies, and to re-evaluate the role of surgery in head and neck cancer treatment.

Traditional transcutaneous approaches in head and neck surgery

The treatment of laryngeal and hypopharyngeal malignancies remains a challenging task for the head and neck surgeon as the chosen treatment modality often has to bridge the gap between oncologically sound radicality and preservation of function. Due to the increase in transoral laser surgery in early tumor stages and chemoradiation in advanced stages, the usage of traditional transcutaneous approaches has decreased over the recent past. In addition, the need for a function-sparing surgical approach as well as highest possible quality of life has become evident. In view of these facts, rationale and importance of traditional transcutaneous approaches to the treatment of laryngeal and hypopharyngeal malignancies are discussed in a contemporary background. The transcutaneous open partial laryngectomies remain a valuable tool in the surgeon's armamentarium for the treatment of early and advanced laryngeal carcinomas, especially in cases of impossible laryngeal overview using the rigid laryngoscope. Open partial laryngetomies offer superior overview and oncologic safety at the anterior commissure, especially in recurrencies. In select advanced cases and salvage settings, the supracricoid laryngectomy offers a valuable tool for function-preserving but oncologically safe surgical therapy at the cost of high postoperative morbidity and a very demanding rehabilitation of swallowing.In hypopharyngeal malignancies, the increasing use of transoral laser surgery has led to a decline in transcutaneous resections via partial pharyngectomy with partial laryngectomy in early tumor stages. In advanced stages of tumors of the piriform sinus and the postcricoid area with involvement of the larynx, total laryngectomy with partial pharyngectomy is an oncologically safe approach. The radical surgical approach using circumferent laryngopharyngectomy with/without esophagectomy is indicated in salvage cases with advanced recurrences or as a primary surgical approach in patients where chemoradiation does not offer sufficient oncologic control or preservation of function. In cases with impending reconstruction, fasciocutaneous free flaps (anterolateral thigh flap, radial forearm flap) seem to offer superior results to enteric flaps in cases where the cervical esophagus is not involved leading to better voice rehabilitation with fewer complications and postoperative morbidity. In salvage situations, the Gastroomental Free Flap has proven to be a valuable tool.In conclusion, the choice of a surgical treatment modality is influenced by the patient's anatomy, tumor size and location as well as the surgeon's personal expertise.

Radiotherapy for stage I or II hypopharyngeal carcinoma

Hypopharyngeal squamous cell carcinoma (HPSCC) is usually diagnosed at an advanced stage, and early-stage HPSCC is relatively rare. Because of the rarity of early-stage HPSCC, few reports have been published on the efficacy of radiotherapy (RT) in its treatment. We retrospectively reviewed the clinical records of 45 consecutive patients with Stage I and II HPSCC from May 1991 to June 2010. Patient characteristics were as follows: median age, 66 years (range, 44-90 years); male/female, 39/6; and T1/T2, 27/18. The irradiation dose ranged from 60 to 72 Gy (median: 70 Gy). Of the 45 patients, 21 underwent concurrent chemotherapy. With a median follow-up period of 62 months, the 5-year overall survival rate was 81%. Local failure occurred in 5 patients, and the 5-year local control rate was 83%. All local recurrences were successfully salvaged by surgery. The 5-year functional larynx preservation rate was 92%. Acute toxicity was manageable. Grade 3 laryngeal edema and Grade 3 hypothyroidism occurred in 1 patient each. No other late adverse events of Grade 3 or greater were observed. Based on these results, RT seemed to be an effective treatment modality for early HPSCC, with favorable organ preservation and acceptable adverse events. Early detection and accurate management of local recurrence and second malignancy was deemed to be critical.

Functional organ preservation in laryngeal and hypopharyngeal cancer

The principles of open versus laser microsurgical approaches for partial resections of the larynx are described, oncologic as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.

Current trends in initial management of hypopharyngeal cancer: the declining use of open surgery

Squamous cell carcinoma of the hypopharynx represents a distinct clinical entity. Most patients present with significant comorbidities and advanced-stage disease. The overall survival is relatively poor because of high rates of regional and distant metastasis at presentation or early in the course of the disease. A multidisciplinary approach is crucial in the overall management of these patients to achieve the best results and maintain or improve functional results. Traditionally, operable hypopharyngeal cancer has been treated by total (occasionally partial) laryngectomy and partial or circumferential pharyngectomy, followed by reconstruction and postoperative radiotherapy in most cases. Efforts to preserve speech and swallowing function in the surgical treatment of hypopharyngeal (and laryngeal) cancer have resulted in a declining use of total laryngopharyngectomy and improved reconstructive efforts, including microvascular free tissue transfer. There are many surgical, as well as nonsurgical, options available for organ and function preservation, which report equally effective tumor control and survival. The selection of appropriate treatment is of crucial importance in the achievement of optimal results for these patients. In this article, several aspects of surgical and nonsurgical approaches in the treatment of hypopharyngeal cancer are discussed. Future studies must be carefully designed within clearly defined populations and use uniform terminology and standardized functional assessment and declare appropriate patient or disease endpoints. These studies should focus on improvement of results, without increasing patient morbidity. In this respect, technical improvements in radiotherapy such as intensity-modulated radiotherapy, advances in supportive care, and incorporation of newer systemic agents such as targeted therapy, are relevant developments.

Three-dimensional reconstruction of supraglottic structures after partial pharyngolaryngectomy for hypopharyngeal cancer

OBJECTIVE

Larynx-preserving surgery is frequently performed for advanced hypopharyngeal cancer involving the larynx. However, reconstruction after partial pharyngolaryngectomy (PPL) remains a challenging problem because of the high risk of postoperative aspiration. In this report, we describe our new three-dimensional method for reconstructing supraglottic structures with a radial forearm flap. This is a retrospective analysis of 20 patients who underwent PPL for having hypopharyngeal cancer involving the larynx at our institution from 1996 to 2005.

METHODS

The resulting pharyngolaryngeal defects were reconstructed with radial forearm flaps in all patients. Three-dimensional structures were reconstructed with a single nylon suture, which was used to hoist the flap and ensures that the arytenoids and the aryepiglottic fold were of appropriate height.

RESULTS

Radial forearm flaps were transferred successfully in all but one case. Swallowing function was satisfactory in all patients, and decannulation could be performed in all but one patient. Postoperative conversational function in all patients was rated as excellent with Hirose's scoring system.

CONCLUSIONS

Free jejunum transfer is the method of first choice for reconstruction of a defect after partial hypopharyngectomy. However, the complex supraglottic structures of the larynx are difficult to reconstruct with a free jejunal graft after PPL. In such cases, we perform three-dimensional reconstruction of the pharyngolaryngeal defect with a radial forearm flap and have achieved satisfactory postoperative function. We believe that our new procedure is a useful method for functional reconstruction after PPL.

A simple predictive model for postoperative mortality after head and neck cancer surgery with opening of mucosa

The aim of this study was to determine the risk factors for the mortality during the first 30 days after a major head and neck cancer surgery. Two hundred and sixty one consecutive surgical procedure were prospectively studied at Oscar Lambret Cancer Centre within a 36-months period. Twenty variables were recorded for each patient. The significant risk factors for postoperative mortality were assessed by univariate and multivariate analysis. Overall 30-days mortality rate was 3.83% [95% CI 3.13-4.53]. In univariate analysis identified four risk factors: female gender (odd ratio 4.25 [95% CI 1.03-17.56]), age equal or superior than 70 (odd ratio 5.06 [95% CI 1.35-18.36]), current alcohol addiction (odd ratio 3.65 [1.02-13.06]) and laryngeal location (odd ratio 4.23 [CI 95% 1.18-3.38]). In multivariate analysis only female gender and laryngeal location remained significant. The incidence of postoperative mortality was 1.63% for patients without risk factor and was 6.41% for those with one or two risk factors. This model identifies easily high-risk patients for major head and neck cancer surgery. A multicenter validation is necessary.

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

PURPOSE OF REVIEW

This paper reviews recent surgical contributions to the multidisciplinary approach to head and neck cancer treatment as well as published data on pertinent questions in the field.

RECENT FINDINGS

The role of surgery in the strategy of organ preservation via chemoradiation, including treatments of complications and locoregional recurrences, such as when N1-N3 necks should be operated on and the role of CT and positron emission tomography (PET) scanning. Also covered are the role of sentinel lymph node biopsy for the detection of occult micrometastases in the N0 neck and the value of fluorodeoxyglucose PET scanning combined with the former. Transoral laser surgery for tumors of the larynx or of the hypopharynx is discussed, as is a new technique of reconstruction involving the anterolateral thigh free flap. Also included are quality of swallowing after resections and reconstruction of the oral cavity and orpharyngeal tumors.

SUMMARY

Surgery must define its role in the multidisciplinary treatment of advanced cancers, which currently often favors (chemo)radiotherapy protocols. Organ sparing by transoral laser surgery for laryngeal and hypopharyngeal cancer has established itself within our armamentarium and its exact role will be further refined. Larger and well-executed studies on sentinel lymph node biopsy in the clinically negative neck are needed before this procedure can be implemented in our routines. The latest addition, the anterolateral thigh flap, to further decrease patients' morbidity is unlikely to completely replace the currently favored radial forearm flap in soft tissue replacement of the head and neck. Outcome analysis, including swallowing, is a major step that surgeons should further investigate.