Oncologic outcomes of total laryngectomy: Impact of margins and preoperative tracheostomy

Laryngectomy Margin Assessment: A Little Help From a Template

Laryngectomy margin assessment is an important part of patient care and can affect outcomes. There is no standard approach to grossing laryngectomy specimens, with variations in the published guidelines. A uniform approach to margin assessment may be helpful to improve patient care and future research. At the very least, sampling of all mucosal margins (arytenoid area, hypopharyngeal, and anterior epiglottis) and tracheal margin should be performed. Sampling of soft tissue margins may be delegated to the pathologist, and contingent on the tumor extent into soft tissue. If a tracheostomy is present, skin and soft tissue margins should be sampled from the stoma. This review provides a template for laryngectomy margin assessment and can be used as a guideline as to which margins should be assessed.

[Surgical Treatment of Hypopharyngeal Carcinoma, Neck Dissection and Adjuvant Postoperative Therapy of Oropharyngeal and Hypopharyngeal Cancer: Recommendations of the current S3 Guideline - Part II]

Part II of the S3 guideline report deals with the surgical treatment of hypopharyngeal carcinoma, neck dissection for oropharyngeal and hypopharyngeal carcinomas and adjuvant therapy options. Primary surgical therapy ± adjuvant radio- or radiochemotherapy and primary radio- or radiochemotherapy are established as primary therapies for local-regional hypopharyngeal carcinomas. Direct randomized comparisons of both basic therapeutic procedures were never conducted. Available registry data show a worse prognosis of hypopharyngeal carcinoma compared to oropharyngeal carcinomas in all locoregional tumor stages, regardless of the treatment method. For T1N0-T2N0 squamous cell carcinoma of the hypopharynx, there are no relevant differences in overall survival and locoregional relapse rate between primary surgical and primary non-surgical treatment. Primary surgical therapy ± adjuvant radiotherapy or radiochemotherapy and primary radiotherapy or radiochemotherapy are established as primary therapies for advanced but locoregionally limited hypopharyngeal carcinomas. Neck dissection is an integral part of the primary surgical treatment of oropharyngeal and hypopharyngeal cancer. There are only a few randomized studies on non-surgical organ preservation for advanced hypopharyngeal cancer as an alternative to pharyngolaryngectomy, but these have led to the recommendation of alternative concepts in the new guideline. The indication and implementation of postoperative adjuvant radiotherapy and radiochemotherapy for hypopharyngeal carcinoma do not differ from those for HPV/p16-negative and -positive oropharyngeal carcinoma.

Clinical Relevance of Resection Margins in Patients with Total Laryngectomy or Laryngopharyngectomy

BACKGROUND

Laryngeal and hypopharyngeal cancer is complex and resection margins are therefore constrained. The aim of this study was to investigate the clinical relevance of resection margins in laryngeal and hypopharyngeal surgery.

METHODS

A retrospective cohort study was performed for patients treated with a total laryngectomy (TL) or laryngopharyngectomy (TLP) for laryngeal or hypopharyngeal squamous cell carcinoma (LSCC and HSCC, respectively). Within the groups primary LSCC, recurrent LSCC, primary HSCC, and recurrent HSCC the relationship between the status of the resection margin according to the Royal Collage of Pathology and the recurrence and survival rates were investigated.

RESULTS

Positive resection margins were found in 54% for primary LSCC, 29% for recurrent LSCC, 62% for primary HSCC, and 44% for recurrent HSCC. For primary and recurrent LSCC, there was a linear association between total recurrence and narrowing margins (p = 0.007 resp. p = 0.008). Multivariate survival analysis for primary and recurrent LSCC showed a significantly worse disease free and disease-specific survival in case of positive margins compared to clear margins.

CONCLUSION

Similar survival rates were recorded for close and clear margins for primary and recurrent LSCC. This may suggest that a margin > 5 mm is not clinically relevant in terms of survival. Therefore, a margin of 1-5 mm should be accepted in certain subsites. Margins < 1 mm are related to significantly worse outcomes and should be avoided.

Preoperative tracheostomy is associated with thyroid gland invasion and poorer prognosis in laryngectomized patients

PURPOSE

Patients with laryngeal cancer may necessitate tracheostomy placement to alleviate compromised airways. However, the impact of tracheostomy on thyroid gland invasion and its implications for prognosis in individuals who further undergo total laryngectomy remains unclear. This study aimed to assess thyroid gland invasion rates and explore the 5-years disease-free and overall survival in laryngectomized patients stratified by preoperative tracheostomy.

METHODS

All patients who underwent total laryngectomy for laryngeal cancer between 2003 and 2023 at a tertiary referral center were retrospectively reviewed. Logistic univariable and multivariable regressions were performed to identify factors associated with thyroid gland invasion. Survival analyses were performed using the Kaplan-Meier estimator.

RESULTS

A total of 119 laryngectomized patients were included (mean age: 63 ± 10 years, range 35-89, 110 [92.4%] males); 27 (22.7%) underwent preoperative tracheostomy. In 16 (13.4%) patients, tumor cells were found within the thyroid gland. In a multivariable analysis, thyroid gland invasion was independently associated with preoperative tracheostomy (odds ratio [OR] 3.13, 95% confidence interval [CI] 2.45-6.19), pN2 + (OR 2.13, 95% CI 1.8-5.14), positive margins (OR 1.36, 95% CI 1.01-1.77), lower 5-year disease-free survival (38% vs. 57%, p = 0.01), and lower 5-year overall survival (40% vs. 56%, p = 0.03).

CONCLUSION

Preoperative tracheostomy is an independent predictive factor for thyroid gland invasion and has adverse oncological outcomes in laryngectomized patients. Conversely, the rates of thyroid gland invasion are low when tracheostomy was not performed beforehand.

Airway Resistance and Respiratory Distress in Laryngeal Cancer: A Computational Fluid Dynamics Study

BACKGROUND

Obstructive upper airway pathologies are a great clinical challenge for the airway surgeon. Protection against acute obstruction is critical, but avoidance of unnecessary tracheostomy must also be considered. Decision-making regarding airway, although supported by some objective findings, is largely guided by subjective experience and training. This investigation aims to study the relationship between clinical respiratory distress and objective measures of airway resistance in laryngeal cancer as determined by computational fluid dynamic (CFD) and morphometric analysis.

METHODS

Retrospective CT and clinical data were obtained for series of 20 cases, defined as newly diagnosed laryngeal cancer patients who required admission or urgent airway surgery, and 20 controls. Cases and controls were matched based on T-staging. Image segmentation and morphometric analysis were first performed. Computational models based on the lattice Boltzmann method were then created and used to quantify the continuous mass flow, rigid wall, and constant static pressure inlet boundary conditions.

RESULTS

The analysis demonstrated a significant relationship between airway resistance and acute obstruction (OR 1.018, 95% CI 1.001-1.045). Morphometric analysis similarly demonstrated a significant relationship when relating measurements based on the minimum cross-section, but not on length of stenosis. Morphometric measurements also showed significance in predicting CFD results, and their relationship demonstrated that airway pressures increase exponentially below 2.5 mm. Tumor subsite did not show a significant difference, although the glottic subgroup tended to have higher resistances.

CONCLUSION

Airway resistance analysis from CFD computation correlated with presence of acute distress requiring emergent management. Morphometric analysis showed a similar correlation, demonstrating a radiologic airway assessment technique on which future risk estimation could be performed.

LEVEL OF EVIDENCE

4 (case-control study) Laryngoscope, 133:2734-2741, 2023.

Impact of COVID-19 pandemic on head-neck cancer referral and treatment pathway in North East London

INTRODUCTION

The COVID-19 pandemic has led to wide-ranging disruption of head-neck cancer (HNC) service provision in the UK. Early reports suggest delays in referral, diagnosis and initiation of treatment for new cancer cases compared with before the pandemic.

METHODS

The HNC service was studied retrospectively for the time-periods between 1 January 2020 to 31 October 2020 (hereafter 'post-COVID') and 1 January 2019 to 31 October 2019 (hereafter 'pre-COVID'). We analysed: (1) the number of cases treated at our centre, (2) stage of disease at presentation and (3) treatment delivery times.

RESULTS

In the post-COVID period, the total number of HNC cases treated decreased (48 vs 56 pre-COVID). There was increase in advanced stage at presentation (58% vs 42% pre-COVID) and a significant increase in the need for airway stabilisation (13 vs 5 pre-COVID; p=0.03). Average time from referral to treatment was significantly prolonged (72.5 days vs 49.23 days pre-COVID; p=0.03). Two-week wait referrals were seen in HNC clinics at median time of 11.9 days, compared with 7.1 days during the pre-COVID period (p=0.07). However, there was no delay in the initiation of first treatment after the decision to treat (29.2 days vs 24.7 days pre-COVID; p=0.58).

CONCLUSION

The results of this study call for early referral at the primary care level and rapid radiopathological confirmation at the tertiary level to prevent delays in diagnosis of new HNC cases.

Effects of Prior Tracheostomy on Total Laryngectomy Outcomes

OBJECTIVE

To assess whether preoperative tracheostomy (PreOT) increases risk of complications after total laryngectomy (TL) and to determine if timing of tracheostomy creation is associated with an increased risk.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care hospital between 2007 and 2020.

METHODS

Inclusion criteria were patients who underwent primary or salvage TL for oncologic treatment. Dependent variables of interest included surgical complications, such as wound dehiscence, infection, hematoma, complete flap failure, fistula formation, and stoma stenosis, as well as medical complications. Categorical variables were compared with chi-square test or Fisher exact test, and continuous variables were compared with an independent t test. Multivariable regression was conducted to assess predictors of complications after laryngectomy.

RESULTS

A total of 306 patients were included. Primary TL was performed in 161 (53%) patients and salvage in 145 (47%) patients. Of the patients undergoing primary laryngectomy, 105 (65%) received a PreOT. Of the patients undergoing salvage laryngectomy, 86 (59%) received a PreOT. In both primary and salvage cases, there was no association between PreOT and surgical or medical complications. Additionally, there was no significant association between timing of tracheostomy and surgical complications. On multivariable analysis, the presence of a PreOT was not associated with surgical complications. In salvage cases, those with a PreOT had a significantly longer average length of stay than those without a PreOT (12 vs 9 days, P = .008).

CONCLUSION

PreOT in patients undergoing primary and salvage laryngectomies was not associated with surgical or medical complications postlaryngectomy. Timing of tracheostomy in relation to laryngectomy was not found to adversely affect clinical outcomes.

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.

Factors predicting pharyngocutaneous fistula in patients after salvage laryngectomy for laryngeal malignancy - A multicenter collaborative cohort study

OBJECTIVES

Pharyngocutaneous fistula (PCF) is a major morbidity of salvage total laryngectomy (TL). Understanding the factors predicting PCF is fundamental to managing laryngeal cancer. We aim to assess factors associated with PCF following salvage TL in a multicenter, international retrospective cohort study of academic centers in the US and Canada.

RESULTS

In total, 550 patients post-salvage TL were identified (mean [SD; range] age, 64 [10.4; 32-90] years; 465 [85 %] male and 84 [15 %] female) between 2000 and 2014. Rate of PCF was 23 % (n = 127) with median time to PCF of 2.9 weeks. Surgical management of PCF was required in 43 % (n = 54) while 57 % (n = 73) required wound care alone. Rates of PCF differed by primary treatment modality [radiation, 20 % (n = 76); chemoradiation, 27 % (n = 40); not available (n = 6)] and use of vascularized tissue in pharyngeal closure [free/regional flap, 18 % (n = 25); no vascularized tissue/primary closure, 24 % (n = 98); not available (n = 4)]. There was no statistically significant association between PCF and treatment with chemoradiation (HR, 1.32; 95 % CI, 0.91-1.93, p = 0.14) or lack of vascularized tissue reconstruction (HR, 1.41, 95 % CI 0.91-2.18, p = 0.12). Significant association between PCF and advanced stage (T3 or T4), positive margin, close margin (<5mm), lymphovascular invasion and pre-operative tracheostomy were identified on univariable analysis. Positive surgical margin (HR, 1.91; 95 % CI, 1.11 to 3.29) was the only significant association on multivariable analysis.

CONCLUSION

We highlight positive surgical margin as the only variable significantly associated with increased risk of PCF following salvage TL on multivariable analysis in a large cohort across several major head and neck oncology centers.

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.

Transtracheal jet ventilation in a general tertiary hospital: A 7-year audit

Airway management in patients presenting with severe airway obstruction can present a challenge to the anaesthetist, as conventional difficult airway pathways are often inappropriate. The use of a transtracheal jet cannula is an alternative means of airway securement, but lack of familiarity has limited its use in general tertiary hospitals. We report a retrospective audit of the use of transtracheal jet ventilation in a general tertiary healthcare centre over the past seven years, with a total of 50 patients with severe airway compromise undergoing pharyngolaryngeal surgery. Transtracheal jet ventilation was successful in 98% of patients, and was the definitive means of airway management in 43 cases. In six cases, the technique was a useful temporising measure while the airway was secured by other means. Minor complications occurred in 12% of patients. No major morbidities or mortalities were recorded. We conclude that transtracheal jet ventilation for high-risk pharyngolaryngeal surgery can be performed using a high frequency jet ventilator, with a high rate of success and only minor complications. Cannulation of the trachea below the cricothyroid membrane is feasible but more challenging. Low-flow apnoeic oxygenation through the transtracheal jet ventilation cannula maintains oxygenation during initial surgical airway manipulation.

Survival Outcomes and Predictors for Patients who Failed Chemoradiotherapy/Radiotherapy and Underwent Salvage Total Laryngectomy

Background: To assess the presence of adverse pathological features at the time of salvage total laryngectomy (TL) associated with oncologic outcome. Methods: Ninety patients with persistent/locally recurrent disease and who subsequently underwent salvage TL after definitive treatment by radiation alone (RTO) or concurrent chemo-radiation (CCRT) from 2009 to 2018 were retrospectively enrolled. Kaplan–Meier methods were used to estimate overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). Results: Lymphovascular invasion (LVI), perineural invasion, positive margin, and stage IV disease were associated with worse survival in the univariate analysis. In the multivariate analysis, the presence of LVI and positive margin were both independent negative predictors in OS (LVI: adjusted hazard ratio (aHR) = 2.537, 95% CI: 1.163–5.532, p = 0.019; positive margin: aHR = 5.68, 95% CI: 1.996–16.166, p = 0.001), DSS (LVI: aHR = 2.975, 95% CI: 1.228–7.206, p = 0.016); positive margin: aHR = 11.338, 95% CI: 2.438–52.733, p = 0.002), and DFS (LVI: aHR 2.705, 95% CI: 1.257–5.821, p = 0.011; positive margin (aHR = 6.632, 95% CI: 2.047–21.487, p = 0.002). Conclusions: The presence of LVI and positive margin were both associated with poor OS, DSS, and DFS among patients who underwent salvage TL after failure of RTO/CCRT. The role of adjuvant therapy for high-risk patients after salvage TL to improve the chance of survival requires more investigation in the future.

Impact of Lymph Node Yield in Patients Undergoing Total Laryngectomy and Neck Dissection

OBJECTIVES

To determine the impact of lymph node yield (LNY) in patients undergoing neck dissection at the time of total laryngectomy (TL). To determine the impact of radiation therapy (RT) on LNY.

METHODS

Retrospective review of LNY and clinical outcomes in 232 patients undergoing primary or salvage total laryngectomy (TL) with ND.

RESULTS

Preoperative RT significantly decreased mean LNY from 31.7 to 23.9 nodes (P < .001). In primary TL patients, age (P < .001) and positive margins (P = .044) were associated with decreased OS. In salvage TL patients, only positive margins was associated with poorer OS (P = .009). No LNY cutoff provided significant OS or DFS benefit.

CONCLUSIONS

Radiotherapy significantly reduces LNY in patients undergoing TL and ND. Within a single institution cohort, positive margins, but not LNY, is associated with survival in both primary and salvage TL patients.Level of Evidence: 4.

Long-term outcomes of trans-oral robotic surgery-assisted total laryngectomy for recurrent laryngeal cancers

OBJECTIVE

For recurrent laryngeal cancers, trans-oral robotic surgery has been used to perform total laryngectomy, but limited cases had been reported without long-term outcome follow-up. This study aims at presenting the largest longitudinal retrospective cohort in a single tertiary referral medical center.

METHODS

From November 2013 to August 2017, seven patients with recurrent laryngeal cancers without evidence of neck metastasis were selected to receive trans-oral robotic surgery-assisted TL without neck dissection. The para-operative details including the surgical success rates, surgical methods, resection extent, drainage tube placement, pharyngeal wound closure, console surgical time, pathologic findings and long-term complications were reviewed and described. The study end points include survival rates and preservation of swallowing function without tube feeding.

RESULTS

Trans-oral robotic surgery-assisted total laryngectomy was successfully performed on all seven patients with mean surgical console time of 111 ± 66 min. Strap muscles and hyoid bone were resected like open surgery in six and five patients, respectively. For all the seven patients, there was no severe pharyngo-cutaneous fistula formation requiring repair in a second surgery, but tracheostoma stenosis was not uncommon (57%). Three patients received adjuvant chemotherapy/radiotherapy. After follow-up of 36.1 ± 15.8 months, two patients had neck recurrence, and one patient died 19 months after surgery, but the other five patients were alive without disease recurrence. The overall survival rate was 85.7% (6/7), and all patients had good swallowing function without tube feeding.

CONCLUSIONS

Trans-oral robotic surgery-assisted total laryngectomy is a feasible approach for selected patients with recurrent laryngeal cancers. The oncologic and functional outcomes were satisfactory. Further larger cohort study is worthwhile to further elucidate the value of trans-oral robotic surgery-assisted total laryngectomy.

Association of Positive Initial Margins With Survival Among Patients With Squamous Cell Carcinoma Treated With Total Laryngectomy

Importance

Frozen-section analysis of margin status is routinely performed during total laryngectomy for squamous cell carcinoma; in the case of positive initial frozen margins, re-resection to negative margins can often be accomplished. Some evidence suggests that positive initial margins may be associated with worse survival among patients with head and neck cancer even when final margins are negative, but the significance of positive initial frozen margins in total laryngectomy is poorly understood.

Objective

To determine the association between disease-free survival and positive initial margins among patients treated with total laryngectomy for squamous cell carcinoma.

Design, Setting, and Participants

In this retrospective cohort study conducted at a tertiary care center, records of 237 consecutive patients treated with total laryngectomy for squamous cell carcinoma from February 2008 to July 2016 were reviewed for demographic characteristics, disease staging, pathologic markers, and outcomes. Margins were considered to be positive if they contained invasive carcinoma, carcinoma in situ, or severe dysplasia. Data analysis was performed from March to June 2018.

Interventions

All patients had undergone total laryngectomy for squamous cell carcinoma.

Main Outcomes and Measures

Variables associated with disease-free survival were analyzed using a univariable and multivariable Cox proportional hazards model.

Results

Among all 225 patients (184 [92%] male; mean age, 63.9 years; range, 30-92 years) who underwent total laryngectomy and had negative final margins, 127 patients underwent primary total laryngectomy and 98 underwent salvage total laryngectomy, with mean (SEM) follow-up of 29.3 (1.8) months. Initial frozen margins were positive in 40 of 225 patients (18%); positive initial margins occurred in 21 of 127 patients who underwent primary total laryngectomy (17%) and in 19 of 98 patients who underwent salvage total laryngectomy (19%). On multivariable analysis, only salvage laryngectomy was associated with significantly worse disease-free survival (hazard ratio [HR], 3.35; 95% CI, 1.76-6.36). Among 98 patients who underwent salvage total laryngectomy, positive lymph nodes, lymphovascular invasion, extracapsular nodal extension, and adjuvant therapy were associated with worse disease-free survival on univariable analysis, but no factors remained significant on multivariable analysis. Among 127 patients who underwent primary total laryngectomy, positive nodes, lymphovascular invasion, extracapsular nodal extension, and positive initial margins were associated with worse disease-free survival; however, only positive initial margins were associated with significantly worse disease-free survival on multivariable analysis (HR, 5.01; 95% CI, 1.55-16.2).

Conclusions and Relevance

In this study, positive initial margins were associated with worse disease-free survival among patients who underwent primary total laryngectomy despite negative margins on final pathologic examination. This finding may indicate aggressive tumor behavior in the context of primary laryngeal squamous cell carcinoma.

Prognostic role of resection margin in open oncologic laryngeal surgery: survival analysis of a cohort of 139 patients affected by squamous cell carcinoma

INTRODUCTION

The treatment of laryngeal squamous cell carcinoma needs accurate risk stratification, in order to choose the most suitable therapy. The prognostic significance of resection margin is still highly debated, considering the contradictory results obtained in several studies regarding the survival rate of patients with a positive resection margin.

OBJECTIVE

To evaluate the prognostic role of resection margin in terms of survival and risk of recurrence of primary tumour through survival analysis.

METHODS

Between 2007 and 2014, 139 patients affected by laryngeal squamous cell carcinoma underwent partial or total laryngectomy and were followed for mean of 59.44±28.65 months. Resection margin status and other variables such as sex, age, tumour grading, pT, pN, surgical technique adopted, and post-operative radio- and/or chemotherapy were investigated as prognostic factors.

RESULTS

45.32% of patients underwent total laryngectomy, while the remaining subjects in the cohort underwent partial laryngectomy. Resection margins in 73.39% of samples were free of disease, while in 21 patients (15.1%) anatomo-pathological evaluation found one of the margins to be close; in 16 subjects (11.51%) an involved resection margin was found. Only 6 patients (4.31%) had a recurrence, which occurred in 83.33% of these patients within the first year of follow-up. Disease specific survival was 99.24% after 1 year, 92.4% after 3 years, and 85.91% at 5 years. The multivariate analysis of all covariates showed an increased mortality rate only with regard to pN (HR=5.043; p=0.015) and recurrence (HR=11.586; p=0.012). Resection margin did not result an independent predictor (HR=0.757; p=0.653).

CONCLUSIONS

Our study did not recognize resection margin as an independent prognostic factor; most previously published papers lack unanimous, methodological choices, and the cohorts of patients analyzed are not easy to compare. To reach a unanimous agreement regarding the prognostic value of resection margins, it would be necessary to carry out meta-analyses on studies sharing definition of resection margin, methodology and post-operative therapeutic choices.

Laser debulking or tracheotomy in airway management prior to total laryngectomy for T4a laryngeal cancer

PURPOSE

Retrospective studies have shown that tracheotomy prior to total laryngectomy (TL) is associated with decreased survival. We sought to investigate whether this is due to higher local invasiveness associated with obstructive disease or whether it is the result of tracheotomy itself.

METHODS

We reviewed patients with a T4a (AJCC 7th edition) laryngeal squamous-cell carcinoma treated with a primary TL followed by adjuvant radiotherapy between 2001 and 2013. We compared patients who had obstructive lesions with those who had non-obstructive lesions in terms of preoperative data, pathological features, and treatment outcomes. Second, we compared tracheotomized patients with patients who underwent endoscopic laser debulking (ELD).

RESULTS

One hundred patients were reviewed. Thirty-seven of them required an airway intervention prior to a TL (tracheotomy n = 24/ELD n = 13). Patients with obstructive tumors had more frequently subglottic extension (p = 0.0066) and a shorter disease-free survival (DFS) (p = 0.046), due to a higher incidence of additional distant metastases. Tracheotomy was associated with a shorter DFS (p = 0.035) and more frequent perineural invasion (p = 0.0272) as compared to ELD, but not with a higher incidence of stomal recurrence.

CONCLUSIONS

A tracheotomy prior to a total laryngectomy is associated with decreased survival. We recommend laser debulking as the preferred treatment whenever management of an obstructive airway is required prior to a total laryngectomy.

Long-term results of Amatsu tracheoesophageal shunt: Follow-up of more than 5 years

BACKGROUND/OBJECTIVE

The Amatsu tracheoesophageal shunt (ATES) represents a nonprosthesis surgical option for voice restoration in laryngectomized patients. However, data regarding the long-term efficacy of ATES are lacking.

STUDY DESIGN

Retrospective, single-institution study.

METHODS

Between 2001 and 2010, 16 patients with laryngeal cancer underwent total laryngectomy with ATES at the Hyogo Cancer Center (Akashi, Hyogo, Japan). Of these, 11 achieved long-term tracheoesophageal speech that was maintained for a follow-up exceeding 5 years (range 75-161 months; median 95 months). All patients were male and ranged from 46 to 74 years of age at the time of ATES surgery.

RESULTS

Of 11 eligible patients, eight were able to speak intelligibly with ATES at last follow-up. Regarding aspiration, three patients experienced no leakage, and six experienced mild leakage of saliva without medical intervention at last follow-up. Almost all patients maintained an unchanged degree of voice quality (9 of 11) and leakage (8 of 11).

CONCLUSION

The favorable voice restoration and low aspiration rates achieved in this study appear to support the long-term efficacy of ATES.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1395-1397, 2018.

Preoperative Tracheostomy Is Associated with Poor Disease-Free Survival in Recurrent Laryngeal Cancer

Objectives It is unknown if preoperative tracheostomy for persistent/recurrent laryngeal squamous cell carcinoma (LSCC) plays a role in unrecognized local disease spread and disease recurrence after salvage laryngectomy. The goals of this study were to determine the effect of preoperative tracheostomy on disease-free survival (DFS) in patients with recurrent/persistent LSCC undergoing salvage laryngectomy. Study Design Retrospective case series derived from prospectively maintained database. Setting Tertiary care academic center. Subjects Patients with recurrent/persistent LSCC after radiation/chemoradiation (RT/CRT) who underwent salvage laryngectomy at the University of Michigan from 1997 to 2015. Methods Demographic, clinical, pathologic, and survival data were collected. Kaplan-Meier survival estimates were performed. Results DFS was worse for patients with tracheostomy prior to laryngectomy than patients without a tracheostomy (5 year: 39% vs 67%; P < .001). Patients with tracheostomy prior to RT/CRT compared to patients with tracheostomy after RT/CRT or patients without a tracheostomy had worse DFS (5-year: 25%, 49%, and 67%, respectively; P < .001). In bivariable analyses controlling for T classification, N classification, or overall stage, preoperative tracheostomy was associated with worse DFS. In multivariable analysis, presence of a preoperative tracheostomy had a worse DFS (hazard ratio, 1.63; 95% confidence interval, 1.00-2.67; P = .048). Conclusion Preoperative tracheostomy is associated with disease recurrence in patients with persistent/recurrent LSCC undergoing salvage laryngectomy, particularly in patients who had tracheostomy prior to completion of initial RT/CRT. Notably, preoperative tracheostomy as a causal factor vs marker for disease recurrence is difficult to ascertain. Nevertheless, clinicians should be aware of the increased risk of locoregional recurrence in patients with preoperative tracheostomy when counseling on surgical salvage and when considering the role of additional therapy.

Tissue-Engineered Larynx: Future Applications in Laryngeal Cancer

Purpose of Review

This article reviews the latest developments in tissue engineering for the larynx with a specific focus on the treatment of laryngeal cancer.

Recent Findings

Challenges in tissue engineering a total larynx can be divided into scaffold design, methods of re-mucosalization, and how to restore laryngeal function. The literature described a range of methods to deliver a laryngeal scaffold including examples of synthetic, biomimetic, and biological scaffolds. Methods to regenerate laryngeal mucosa can be divided into examples that use a biological dressing and those that engineer a new mucosal layer de novo. Studies aiming to restore laryngeal function have been reported, but to date, the optimum method for achieving this as part of a total laryngeal transplant is yet to be determined.

Summary

There is great potential for tissue engineering to improve the treatments available for laryngeal cancer within the next 10 years. A number of challenges exist however and advances in restoring function must keep pace with developments in scaffold design.

Management of advanced laryngeal cancer

Squamous cell carcinoma of the larynx continues to be the commonest head and neck cancer in many Western countries. The larynx plays a key role for many essential functions, including breathing, voice production, airway protection, and swallowing. The goals of laryngeal cancer treatment are thus to provide best possible oncologic control, while optimizing functional outcomes. In recent decades, the treatment paradigm for advanced laryngeal cancer has shifted from one of primary surgery (total laryngectomy) as gold standard, toward non-surgical organ-preserving treatment using radiotherapy or chemoradiotherapy. However, concerns have emerged regarding functional outcomes after chemoradiotherapy, as well as possible decreased overall survival in patients with laryngeal cancer. The purpose of the present review is to review surgical and non-surgical options for treatment of advanced laryngeal cancer, as well as the evidence supporting each of these.