Subtotal Laryngectomy with Epiglottic Reconstruction for Glottic Carcinoma: A Single Institutional Experience

Aim

Laryngeal cancer is a common form of head and neck cancer in Vietnam where the current treatment is surgery. Subtotal laryngectomy with epiglottic reconstruction, a conservative surgery, allows removal of anterior commissure including thyroid cartilage and paraglottic space and provides a maximum restoration of the anatomical structure of the larynx.

Purpose

To evaluate the results, the safety and effectiveness of patients who were treated with subtotal laryngectomy with epiglottic reconstruction.

Material and Method

From January 2012 to July 2017, 42 patients (41 male, 1 female, median age 55.6 years, range 38–75 years) were diagnosed with glottic carcinomas at Vietnam National ENT Hospital, where they underwent a subtotal laryngectomy with epiglottic reconstruction.

Results

Thirty-one patients (73.8%) had T2 glottic carcinoma, 4 (9.5%) T3 glottic carcinoma, and 12 (25.6%) had neck dissection. The arytenoid cartilage on the tumor-bearing side was resected in 11 patients (26.2%). Functional ipsilateral neck dissection was performed in 30 patients. Positive lymph node of stage T2 was 1/31 (3.2%). Postoperative histopathologic examination showed a tumour free of resection margin in 41 patients (97.6%). Only one post-operative complication occurred with bleeding 24 hours after surgery. There was no mortality. The 3- and 5-year overall survival rates were 97.6% and 85.7%, respectively. The rate of local control was 92.9%.

Conclusion

Subtotal laryngectomy with epiglottic reconstruction was performed mostly for T2 and certain T3 glottic carcinomas when there is difficult to safely remove the tumour with transoral laser microsurgery. This surgery appears to be effective for the overall survival and has potential in clinical practice for treating moderate glottic carcinoma.

Endoscopic Transoral Hybrid Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy

Objectives:

The hybrid supracricoid partial laryngectomy with cricohyoidoepiglottopexy (SCPL-CHEP, that is, open partial horizontal laryngectomies OPHL Type IIa) has been described using a flexible next generation robotic surgical platform for manipulation. We sought to evaluate the feasibility of performing this procedure using endoscopic transoral (EndoT) surgical techniques without robotics.

Methods:

Preclinical cadaveric study using two human cadavers. Hybrid SCPL-CHEP was performed with a flexible endoscope for visualization and hand-held instruments for manipulation (SILS Hook monopolar and Dissect, HAVAS LaryngoFIT malleable straight jaw instruments, and Stratafix 4-0 spiral knotless barbed suture).

Results:

EndoT hybrid SCPL-CHEP was successfully performed. The hand-manipulated rigid instruments allowed for transoral incisions and mucosal suturing. We provide the procedural steps of EndoT hybrid techniques.

Conclusions:

EndoT hybrid SCPL-CHEP was technically feasible in the preclinical cadaveric laboratory setting and appeared comparable to the hybrid SCPL-CHEP via transoral robotic surgery (TORS). Selected handheld instruments and flexible endoscopy appear to facilitate minimally invasive surgery of the larynx. This novel procedure and technique warrant further clinical study for consideration of feasibility, applicability, and patient benefit.

Multidisciplinary Care of Laryngeal Cancer

Treatment of larynx cancer has changed dramatically over the past several years. Novel modalities of treatment have been introduced as organ preservation has been developed. In addition, new targeted therapies have appeared, and improvements in radiotherapeutic and surgical techniques have been introduced. Thus, a large variety of treatment options is increasing local control rates and overall survival; however, selecting the most appropriate treatment remains a challenging decision. This article focuses on the multidisciplinary care of early-stage and locally advanced larynx cancer and attempts to sum up different approaches. Moreover, it reviews state-of-the-art treatment in larynx preservation, which has been consolidated in recent years.

Effective strategy for improving health care outcomes: Multidisciplinary care in cerebral infarction patients

Multidisciplinary teams provide effective patient treatment strategies. South Korea expanded its health program recently to include multidisciplinary treatment. This study characterized the relationship between multidisciplinary care and mortality within 30 days after hospitalization in cerebral infarction patients. We used the National Health Insurance claim data (n = 63,895) from 120 hospitals during 2010-2013 to analyze readmission within 30 days after hospitalization for cerebral infarction. We performed χ(2) tests, analysis of variance and multilevel modeling to investigate the associations between multidisciplinary care and death within 30 days after hospitalization for stroke. Deaths within 30 days of hospitalization due to cerebral infarction was 3.0% (n = 1898/63,895). Multidisciplinary care was associated with lower risk of death within 30 days in inpatients with cerebral infarction (odds ratio: 0.84, 95% confidence interval: 0.72-0.99). Patients treated by a greater number of specialists had lower risk of death within 30 days of hospitalization. Additional analyses showed that such associations varied by the combination of specialists (i.e., neurologist and neurosurgeon). In conclusion, death rates within 30 days of hospitalization for cerebral infarction were lower in hospitals with multidisciplinary care. Our findings certainly suggest that a high number of both neurosurgeon and neurologist is not always an effective alternative in managing stroke inpatients, and emphasize the importance of an optimal combination in the same number of hospital staffing.

Practice of laryngectomy rehabilitation interventions: a perspective from South America

PURPOSE OF REVIEW

Treatment of laryngeal cancer will depend on several factors, including tumor factors, patient factors, as well as the technical resource and expertise of the surgical team and treatment center. In developing countries, most patients have their diagnosis performed at advanced stages, with a significant proportion at very advanced locoregionally, which results in a limitation to the use of organ-preserving approaches. A total laryngectomy is still the most frequent treatment for larynx cancer patients. The rehabilitation in such scenarios can be more demanding and can cost more compared with developed countries.

RECENT FINDINGS

For early-stage tumors, function-preserving strategies are mandatory, and can include partial laryngectomies and radiation therapy. In such cases, functional rehabilitation usually is easily achieved, with lower negative impact on the patient's daily life. For advanced tumor stages, a treatment shift toward a more conservative management has been observed. However, the success rates of organ-preserving strategies, mainly with chemoradiation approaches, will rely on a rigorous patient selection process.

SUMMARY

The rehabilitation of laryngectomy patients in developing countries can be more demanding and can cost more compared with developed countries. In such scenarios, some strategies can be employed by the multidisciplinary team, mainly by the surgical and speech-pathology teams, aiming to decrease the costs involved in the rehabilitation of total laryngectomy patients in developing countries.

Prognostic value of hypoxia-inducible factors (angiogenin and endoglin) in open partial laryngectomies: uni- and multivariate analyses

PURPOSE

Advances in transoral laser microsurgery, radiotherapy, and chemotherapy (and their combinations) have reduced the indications for open partial laryngectomies, although they have replaced total laryngectomies in selected advanced or recurrent laryngeal squamous cell carcinomas (LSCCs). Tissue hypoxia in malignancies appears to be strongly associated with tumor cell invasiveness and metastases. Whether hypoxia-inducible factors can contribute to a rational recommendation of open partial laryngectomy should be investigated.

MATERIALS AND METHODS

Fifty consecutive patients who had undergone primary open partial laryngectomy (supraglottic and supracricoid laryngectomies) were investigated, measuring the immunohistochemical expression of the hypoxia-inducible proteins angiogenin and endoglin in their primary LSCCs also with image analysis.

RESULTS

Univariate analysis showed a significantly higher recurrence rate (P = .007) and shorter disease-free survival (P = .0047) in patients with LSCC with endoglin expression more than 9.0%. Multivariate analysis found endoglin expression independently prognostic in terms of disease-free survival (P = .012). Angiogenin expression (in carcinoma or endothelial cells) was not associated with prognosis.

CONCLUSIONS

Endoglin should be further studied as a biomarker of patients with LSCC at higher risk for recurrence after open partial laryngectomy who may benefit from more aggressive treatments. Endoglin expression in positive laryngeal biopsies may prove useful as a parameter for choosing between different surgical and multimodality approaches to controversial LSCC cases.

Oncologic and Functional Outcomes of Partial Laryngeal Surgery for Intermediate-Stage Laryngeal Cancer

Objective

To evaluate the oncologic and functional outcomes of partial laryngeal surgery (PLS) using transoral laser microsurgery (TLM) and supracricoid laryngectomy (SCL) in patients with intermediate-stage laryngeal squamous cell carcinoma (LSCC).

Study Design

Historical cohort study.

Setting

Single tertiary care center.

Subjects and Methods

Retrospective review of oncologic and functional outcomes in intermediate-stage (T2-3/N0-1, stage II and III) LSCC patients who underwent TLM or SCL from 1998 to 2010.

Results

Sixty patients were included, of whom 28 (47%) underwent TLM and 32 (53%) underwent SCL. For the entire cohort, 2- and 5-year probabilities were 86.2% (95% confidence interval [CI], 73.0%-93.2%) and 72.9% (95% CI, 52.4%-85.6%), respectively, for overall survival (OS) and 79.3% (95% CI, 65.6%-88.0%) and 62.4% (95% CI, 41.9%-77.4%), respectively, for recurrence-free survival (RFS). There was no difference between the TLM and SCL cohorts in OS ( P = .542) or RFS ( P = .483). More than 75% of patients avoided adjuvant therapy. Communication Scale and Functional Outcome Swallowing Scale scores at median follow-up of 33 months were 2 or better in 97% and 91% of patients, respectively, reflecting functional voice and swallowing postoperatively. Eighty-eight percent of patients retained a functional larynx.

Conclusion

PLS provides excellent oncologic and functional outcomes for intermediate-stage LSCC and should be considered an alternative to chemoradiation or total laryngectomy in selected patients.

Ventilation of neck breathers undergoing a diagnostic procedure or surgery

Receiving sedation while undergoing a diagnostic procedure or general anesthesia for surgery is challenging for neck breathers including laryngectomees. Unfortunately, most medical personnel including nurses, medical technicians, surgeons, and anesthesiologists caring for laryngectomees before, during, and after surgery are not familiar with their unique anatomy, how they speak, and how to manage their airways during and after the operation. Methods to improve the care are discussed. Educating medical personnel about these issues can improve the care of neck breathers.

Functional organ preservation for laryngeal cancer: past, present and future

OBJECTIVE

Management of laryngeal cancer has focused on improving survival while preserving function. Over the past 20 years, the trends have shifted from surgery to chemoradiotherapy and presently we are facing various challenges. It is imperative to re-examine what has happened and what can be done.

METHODS

Review of the literature along with our experience in the management of functional organ preservation for laryngeal cancer.

RESULTS

There was an increasing use of chemoradiotherapy with a decreasing use of surgery. Inappropriate patient selection along with inability to properly apply salvage surgeries have been presumed to be responsible for survival deterioration in laryngeal cancer. Reports concerning late adverse events after chemoradiotherapy are also increasing. Reconfirmation of the multidisciplinary team approach is imperative. Transoral laser microsurgery can be used for early laryngeal cancer and, in some experienced institutes, for advanced-stage cancers. Supracricoid laryngectomy demonstrated satisfactory oncologic and functional outcomes, based on our experience.

CONCLUSIONS

Treatment selection for larynx preservation should not merely be decided by guidelines but considering each patient's individual condition. Head and neck surgeons are encouraged to take reasonable risks in performing salvage larynx preservation surgery when it is the only option to save a functioning larynx.