Peristomal recurrence following primary total laryngectomy: the enigma of the central compartment neck lymph nodes

PURPOSE OF REVIEW

The practice of primary total laryngectomy (TL) for advanced laryngo-hypopharyngeal cancer has significantly declined in the developed countries. The treatment options most frequently adopted have changed from open surgery to transoral laser or robotic approaches or nonsurgical (bio-chemo-) radiotherapy. Primary TL remains the treatment of choice in the developing world where healthcare resources are limited, especially for the treatment of cancer.

RECENT FINDINGS

Peristomal recurrence (PSR) is quite a serious complication, with an incidence of 6.6% from the published literature (mainly concerning the developed world), most diagnosed within 2 years, and associated with >80% mortality. The major risk factors include pretreatment tracheostomy, specific primary tumor subsites, positive surgical margins, and presence of nodal metastasis. The treatment options are limited and most success has been observed with surgery, especially when PSR is diagnosed at an early-stage, which is uncommon. Treatment of advanced-stage disease is usually palliative. Reduction and/or prevention of the known risk factors for PSR remain the goal when performing TL. In particular, central compartment (para- and pretracheal) lymph nodes dissection in case of large tumors with extra-laryngeal and/or subglottic extension or pretreatment tracheotomy plays a paramount role in PSR prevention.

SUMMARY

Research is required to conclude the formulation of guidelines for proper dissection of the central compartment (level VI) lymph nodes as indicated either prophylactically or therapeutically during TL for preventing PSR.

A Rare Case of Aggressive Metastatic Laryngeal Chondrosarcoma Presenting as Bilateral Necrotizing Pneumonia

Laryngeal chondrosarcomas are rare tumors that account for only 0.2% of malignant tumors of the larynx. Approximately 80% of these tumors are low grade and well differentiated and are associated with a good long-term prognosis. Herein, we report a case of a 77-year-old male presenting with acute hypoxic respiratory failure that required intubation and mechanical ventilation. Chest CT showed multiple pulmonary nodules and cavities. He then required a tracheostomy, and a soft tissue mass in the subglottic mass was discovered. A laryngoscopy-guided excisional biopsy of the mass was performed. Histopathological examination confirmed the diagnosis of laryngeal chondrosarcoma. Clinicians should consider metastatic laryngeal chondrosarcoma as a differential diagnosis for lung cavities. Overall, we believe this to be the first case of aggressive laryngeal chondrosarcoma with mediastinal and pulmonary metastasis mimicking necrotizing pneumonia.

Preoperative tracheotomy in the treatment of upper airway obstruction of patients with advanced stage supraglottic carcinoma

BACKGROUND

Preoperative tracheotomy is an effective option that secures upper airway patency in laryngeal carcinoma patients suffering from upper airway obstruction, but the influence of this treatment on oncologic outcomes of laryngeal carcinoma remains controversial. The purpose of this study was to determine the impact of preoperative tracheotomy on overall survival in supraglottic carcinoma patients with tumor obstruction of the upper airway, and explore the potential causes.

MATERIALS AND METHODS

This retrospective study collected 243 consecutive patients with advanced stage supraglottic carcinoma from 2005 to 2010. Preoperative tracheotomy in the management of upper airway obstruction in patients with supraglottic carcinoma was analyzed.

RESULTS

The mean age was 60.9 years at diagnosis, with men accounting for 98.4% of all patients. Thirty nine (16.0%) patients presenting with tumor obstruction of the upper airway required preoperative tracheotomy. T4 stage patients had higher rate of tracheotomy than those of patients with T3 stage (36.8% vs 12.2%). Patients with upper airway obstruction presented with greater tumor area compared with patients without (13.7 cm² vs 9.0 cm²). The optimal cutoff value of tumor area for tracheotomy and OS rate were both at 10 cm². Supraglottic patients with upper airway obstruction receiving preoperative tracheotomy had poorer OS rate compared with patients without. T stage and tumor area were correlated with upper airway obstruction, and these two variables were independent predictors of OS rate in supraglottic carcinoma patients.

CONCLUSIONS

Advanced stage supraglottic carcinoma patients with upper airway obstruction undergoing preoperative tracheotomy experienced worse overall survival. Advanced T stage and greater tumor size were associated with upper airway obstruction, indicating that the negative influence of tumor obstruction on survival may be cause by these two preoperative variables. Therefore, preoperative tracheotomy acts only as an alternative procedure, and is not a prognostic agent.

Preoperative tracheotomy as reflection of tumor size impacting oncologic outcomes of patients with advanced stage glottic carcinoma

PURPOSE

The aim of this study was to evaluate the influence of preoperative tracheotomy on oncologic outcomes of advanced stage glottic carcinoma patients, and to explore the potential reason.

METHODS

We retrospectively analyzed 413 consecutive advanced stage glottic carcinoma patients from January 2005 to December 2010. The correlation of preoperative tracheotomy and potential impacting factor of tumor size involving tumor diameter and tumor area with overall survival (OS) and disease-free survival (DFS) was fully assessed.

RESULTS

Our cohort consisted of 302 (73.1%) patients with T3 and 111 (26.9%) patients with T4, and 98 (23.7%) patients received preoperative tracheotomy. The OS and DFS rates of patients receiving preoperative tracheotomy were worse than those without (5-year OS: 49.3% versus 69.8%; 5-year DFS: 45.3% versus 61.0%). The mean tumor diameter and tumor area of patients with preoperative tracheotomy were greater than those without (3.3 cm versus 2.4 cm, 8.9 cm² versus 4.7 cm²). The optimal cutoff values of tumor diameter and tumor area for tracheotomy were 2.85 cm and 6.64 cm². Tumor diameter and tumor area were correlated with tracheotomy intervention. Furthermore, when considering the potential effect of tumor area in multivariate model, we found that it was a significant factor in survival outcomes but variable of preoperative tracheotomy was not.

CONCLUSION

This study indicates that tumor size is correlated with preoperative tracheotomy, and tracheotomy intervention may be reflection from effect of great tumor size that is a true adverse factor influencing oncologic outcomes of advanced stage glottic carcinoma patients.

Laryngeal chondrosarcoma, case report and literature review

INTRODUCTION

Chondrosarcoma constitutes 0.2% of all malignant tumors of the larynx. Many surgeons treat it with total laryngectomy due to the limited experience with this neoplasm because its rarity, and although several conservative approaches have been proposed, the data of these techniques are limited and based on retrospective series.

PRESENTATION OF CASE

A 52-year-old male with a transglottic submucosal tumor and glottic stenosis in fiberoptic examination showed by tomography a laryngeal tumor that infiltrates vocal cords, glottis, cricoid and thyroid cartilage of 3 × 2.7 × 4 cm. Patient was submitted to total laryngectomy with selective bilateral neck dissection because obstructive tumor. Pathology reported a cricoid cartilage tumor consistent with grade 2 chondrosarcoma.

DISCUSSION

Biopsy by laryngoscopy is considered the standard procedure for the diagnosis of laryngeal tumors, however the need for general anesthesia and the difficulty in intubation in some patients with large tumors make difficult to obtain an adequate biopsy in some cases with submucosal tumor. Conservative surgeries should be individualized based on the size and location of the tumor as well as on the patient's general conditions. Radical treatment is recommended for high-grade and large tumors in which conservative surgery would destabilize the cricoid ring.

CONCLUSION

There is no diagnostic and treatment approach established for laryngeal chondrosarcoma, we believe that percutaneous biopsy would be the diagnostic test of choice because it is less invasive and has a high sensitivity and specificity; it could also identify patients who are candidates for conservative surgeries.

Salivary duct carcinoma of the supraglottis with a distinct presentation: A case report and literature review

RATIONALE

Salivary duct carcinoma (SDC) is a rare and aggressive subtype of salivary gland carcinoma that histologically resembles in situ and invasive ductal carcinoma of the breast. We present the first case of advanced SDC of the minor salivary gland arising from the supraglottis and review the literature on the clinicopathologic characteristics and prognosis of SDC.

PATIENT CONCERNS

A 59-year-old male patient with progressive difficulty in swallowing and a muffled voice for 2 months.

DIAGNOSES

The patient was diagnosed with SDC arising from the supraglottis with extensive tumor invasion into the subsites of the larynx and pharynx.

INTERVENTIONS

Due to impending airway obstruction, the patient underwent CO2 laser debulking surgery. In addition to local disease, lymph node and distant metastases were also noted at diagnosis and concurrent chemoradiation therapy was arranged.

OUTCOMES

Laryngeal function was preserved and tracheostomy was avoided. The patient has survived for >1 year after the initial diagnosis.

LESSONS

SDC is a rare and aggressive subtype of salivary gland carcinoma that histologically resembles in situ and invasive ductal carcinoma of the breast. Here we presented the first case of advanced SDC of the minor salivary gland arising from the supraglottis that was treated with CO2 laser debulking surgery followed by concurrent chemoradiation therapy. Due to their rarity, further studies are required to establish the most effective treatment protocol for advanced SDC.

An innovative approach to tracheotomy in patients with major obstruction of the upper airway

BACKGROUND

Patients with severe dyspnea consecutive to locally advanced obstructive head and neck squamous cell carcinoma (HNSCC) or subglottic stenosis requiring definitive or temporary tracheotomy are frequently difficult to ventilate and intubate.

MATERIALS AND METHODS

We describe a new procedure to perform tracheotomy easily and safely in patients with major obstruction of the upper airway. A catheter, specifically designed for cricothyroidotomy, was inserted into the trachea under local anesthesia. Then, general anesthesia was induced and the catheter was used as a guide for dilatation tracheotomy. From November 2009 to March 2013, the procedure was successfully used in 13 consecutive patients. Twelve out of 13 patients presented severe inspiratory dyspnea and stridor.

RESULTS

During and after the procedure, no complications were reported.

CONCLUSIONS

The reported technique is quickly performed and is a safe way to ensure short and long time ventilation of patients with major obstruction of the upper airway.

Induction chemotherapy in locally advanced pharyngolaryngeal cancers with stridor: is it feasible and safe?

Background. The standard initial management of patients with locally advanced pharyngolaryngeal presenting with stridor is tracheostomy. Tracheostomy has been shown to negatively impact cancer-related outcomes. Methods. Retrospective analysis of prospectively collected data of 9 patients, who underwent induction chemotherapy with the aim of prevention of tracheostomy. Presenting features, time to resolution of stridor, and further management are reported. Results. Eight out of 9 patient received chemotherapy within 12 hours of presentation with stridor. There were 4 patients each with primary hypopharynx and larynx. The stage was IVA in 6 patients and IVB in 2 patients. In all patients receiving immediate chemotherapy, clinical stridor resolved within 48 hours. The radiological response rate was 62.5%. The median reduction in size of tumor was 37%. Conclusion. Immediate neoadjuvant chemotherapy is a feasible and safe option for patients presenting with early stridor and helps in resolution of stridor and avoiding tracheostomy.